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Editor: Thurston Scott Welton, m.d., new york 


Associate Editors: Bradley L. Coley, Tor\: Arnold S. Jackson, Madison; 

E. Eric Larson, Los Angeles 


A D V 1 S O R Y B O A R D j.. 

Claude S. Beck, Cleti.; Clarence J. Berne, Los Angeles; Geo R. Brighton, N-T.; Meredith F. Campbell, N-T., James T. Case,' 
Chicago; Isidore Cohn, N-0.; Frederick A. Coller, Ann Arbor; Paul C. Colonna, Philo.; Gordon S. Fahrni, Winnipeg: Herb- 
ert C. Fett, Broo^yn; Emil Goetsch, Brooklyn; Charles A. Gordon, Brooklyn; Donald Guthrie, Sayre, Pa,; Louis J. Hirschman, 
Detroit: Emile F. Holman, San Francisco; Claude J. Hunt, Kansas City; T. J. Kirwin, NT.; Arthur Krida, N.T.; A. V. S. 
Lambert, NT.; Urban Maes, N-0.; Harrison S. Martland, NeuiarJ;, N.J.; Rudolph Matas, N-0.; Rot D. McClure, Detroit; 
D.W. Gordon Murray, Toronto; H. C. Naffzigler, San Francisco; Emil Novak, Balt.; Clarence R. O'Crowley, 7^ewar\, H-J-; 
Louis E. Phaneuf, Boston; James T. Priestley, Rochester, Minn.; Hubert A. Royster, Raleigh; Henry S. Ruth, Phila.; Robert L. 
Sanders, Memphis; Grant E. Ward, Baltimore; J. H. Woolsey, San Francisco. 


NEW SERIES, VOLUME LJ^XVlX 

JANUARY TO JUNE 
1950 


PUBLISHED MONTHLY BY 

THE AMERICAN JOURNAL OF SURGERY, INC. 

49 West 45th Street, New York 19, N. Y. 

MGML 





CopyniGHT, 1950 

By THE AMERICAN JOURNAL OF SURGERY, Inc. 

All Rights Rcscrted 


Printed in the United States 0/ America 



3 


III^ l^mdcaii Journal of 

VoL. Lxxix Contents • January, 1950 Number One 


Presidential Address 

National and International Responsibilities of the American 

Proctologic Society H. E. Bacon 1 

Anniversary Program 

- First Fifty Years of Proctology. Joseph M. Mathews Oration 

Louis J. Hirschman 5 

History of the Proctologic Section of the Royal Society of 

Medicine A. Hedley Whyte 13 

Historical Highlights of the American Proctologic Society . . Tom E. Smith 19 

The Present Status of Socialised Medicine in England . . A. Lawrence Abel 23 

Papers of the Scientific Sessions 

Anal Ducts and Their Clinical Significance . . . ^ . Cuy L. Kratzer 32 

Hemorrhoids. Etiology and Pathology , . . . O. C. Gass and Jac\ Adams 40 

Present Status of Injection Treatment of Internal Hemorrhoids 

Robert V. Terrell and C. C. Chewning, Jr. 44 
A Study of the Injection Treatment of Internal He'morrhoids 

Using 5 Per cent Phenohin-oil A. C. Pfeifer 49 

Proctocystectomy. The Management of Colostomy with 

Ureteral Transplants Lyon H. Appleby 57 

Hidradenitis Suppurativa Involving the Para-anal Region . . J. B. Christensen 61 

Surgical Pathology of Rectal Cancer Cuthbert E. Du\es 66 

Combined Abdominoperineal Resection . ... . Charles W. Mayo 72 

Perineo-abdominal Excision of the Rectum in One Stage . William B. Gabriel 76 

Anorectal Malignant Melanoma Ronald W. Raven 85 

Epidermoid Carcinoma of the Anus and Rectum. Review of 125 

Cases George E. Bindley 90 

Spreading Ulceration of the Skin Associated with Idiopathic 

Ulcerative Colitis E. C. B. Butler 96 

Surgical Principles in the Treatment of Pilonidal Cyst and Its 

Complications James C. Harberson and E. S. Brintnall 101 

Coccygodynia.'The Mechanism of Its Production and Its Rela' 

tionship to Anorectal Disease . / George H. Thiele 110 

Contents Continued on Page S 




Basal anesthesia by the use of Avertin with amylene hydrate, as a 
simple enema in the patient's own room, eliminates preoperative fear 
and apprehension. Avertin basal anesthesia spares the patient the 
ordeal of “sweating it out" during the customary preoperative prep- 
arations. Furthermore, it reduces the amount of inhalation anesthetic 
needed subsequently by about one half and greatly eases the dis- 
comfort of the immediate postoperative period. 


AVERTIN 

with AMYLENE HYDRATE 

Avertin. brand of Tribromoethanoi 



New York 13'n. Y. Windsor, Ont. 


AVERTIN, trademark reg. U. S. Pat. Off. & Conada 



Ilie terkaa Journal of lur^org 


VoL. LXXIX 


Reg. U. S. Pat. Off., Nov. 3. 1936 


Contents • January, 1950 


Number One 


Low Back and Rectal Pain from an Orthopedic and Proctologic 

Viewpoint. With a Review of 180 Cases- Saul Schapiro 117 

Left-sided Colon David A. Susnow 129 

Sacral Block Anesthesia in Proctologic Operations .... John S. Lundy 137 

Pentothal Sodium in Anorectal Surgery. Analysis of 1,500 Cases 

Ralph E. Crigler 140 

Spinal Anesthesia in Proctology A. Gerson Carmel 144 

Surgical Importance of the Composite Longitudinal Muscle of 
the Anal Canal, External Sphincter and Levator Ani 

Muscles C. LJaunton Morgan 151 

Anatomy of the Pelvic Diaphragm and Anorectal Musculature 

As Related to Sphincter Preservation in Anorectal Surgery 

Harold Courtney; 155 

Plastic Repair of the Incontinent Sphincter Ani .... Paul C. Blaisdell 174 

Case Reports 

Enteric-coated Pills As a Cause of Fecal Impaction . . . Leonard J. Schwade 184 

Ischio-anal Abscess Due to Faulty Technic of Pudendal Block in 

Cbstetrics G. J. Rilling 186 

Colovesical Fistula James T. Jenkins 189 

Anorectal Malignant Melanoma Alexander E. Rosenberg 193 

Thoracocolonic Fistula H. R. Reichman 194 

Extramammary Paget’s Disease of Ano-coccygeo-sacro-gluteii 

Areas Thomas F. TJelson 196 

Papers Read by Title 

Correction of Fecal Incontinence from Operations Involving the 

Terminal B6wel W. Wayne Babcoc\ 198 

Pathogenesis and Treatment of Extensive Atypical Anorectal 

Fistulas R. V. Gorsch and George L. Becker 203 

Ulcerative Colitis — the Panic Disease Simon B. Kleiner 209 

Granulomatous Rectal Stricture. Clinical Response to Diethyl' 

stilbestrol F. George Rehell and Fred E. Bradford 213 

Officers and Council of the American Proctologic Society, 1949-1950. . . . 218 

General Information on Page 6 Advertising Index on 3rd Cover 



%mt!d Information 


T he American Journal of Surgery 
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Phaneuf, Louis E. Indications and technique. 

Am. J. Surg., 25: 446, 1937- 
The author should always place his full address on 
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J\\t American Journal of 

Copyright, 1950 by The Tor\e FubUshing Co., Inc. 

A PRACTICAL JOURNAL BUILT ON MERIT 

Fifty'ninth 'Tear of Publication 

VOL. Lxxix JANUARY, 1950 number one 


() 


f MAms 


NATIONAL AND INTERNATIONAL RESPONSIBILITIES 
OF THE AMERICAN PROCTOLOGIC SOCIETY 

H. E. Bacon, m.d. 


Philadelphia, Pennsylvania 


I T is a privilege to celebrate with you the 
fiftieth anniversary of the founding of the 
American Proctologic Society and to pay 
tribute to our past presidents whose vision, 
ideals and accomplishments have formulated 
our present structure of achievement. 

The half century spanned by this Society is 
not long if measured by the process of the suns 
but it is an infinite distance into the past if 
gauged by the revolutionary changes and events 
which have marked the passing of those five 
decades. Those fifty years have seen beliefs 
once thought immutable, principles once held 
to be eternal, relegated to the dustbins of out- 
worn ideas. During its threshing the dispas- 
sionate flail of time has beaten the good grain 
from the stalks that bore it and the winds have 
carried the chaff into oblivion. Many in other 
fields of activity who for a passing moment 
might have enjoyed the world’s esteem are now 
forgotten but the work of great thinkers and 
the achievements of noble characters in the 
realm of medicine are among the permanent 
acquisitions of this world which abide and 
continue to bless mankind. 

It is good to lose oneself in contemplation . 
of the past and in reflection upon the achieve- 
ments of those who have gone before us. That 
which we see in retrospect and which we regard 
with humility of spirit brings home to us the 


striking succession of cause and effect. We can 
appreciate the far reaching influence of actions 
and incidents which might have appeared 
trivial at the time of their occurrence. We can 
recognize that man is the child of yesterday 
and the parent of tomorrow. We can realize 
that what we are now is indissolubly linked 
with yesterday and that our present activities 
will inevitably set in motion a series of effects 
which will extend into the future. This reflec- 
tion is weighted with the responsibility of 
planning the course of that future. In a world 
in which the only certainty is change, it rests 
with us to determine what form that change 
shall assume. Henri Bergson expressed a 
sentiment which bears out this thought suc- 
cinctly:' “The present contains nothing more 
than the past, and • what is the effect was 
already in the cause.” To the founders of this 
Society and to those who labored for its 
growth and development we represent the 
future. The degree of continued creative 
evolution of the Society will be in direct pro- 
portion to the insight and the wisdom that we 
accept as our responsibility and our willingness 
to work for the results which we desire to see 
accomplished in the years to come. 

While it is entirely proper to venerate the 
past, let us not linger there overlong but con- 
tinue to be active in thought, word and deed ; a 


I 



2 


Presidential Address 


precept which was expressed so clearly by 
Philip James Bailey when he said, 

“We live in deeds, not years, 

In thoughts, not breaths, 

In feelings, not in figures on a dial." 

Because time has wrought new concepts in 
the social structure of the world, our responsi- 
bility to this Society in the future now possesses 
a dual nature: we acknowledge an obligation 
to the younger men and affirm our obligation 
to the medical profession and society through- 
out the world. 

Our national responsibility is divided be- 
tween an obligation to those who will be the 
future custodians of our specialty and one which 
has for its objective the advancement of 
knowledge in all subjects relative to our 
specialty. In its relation to future surgeons of 
the colon and the rectum the status of the 
American Board of Proctology is of utmost 
importance. Such a board will assure us of a 
growing number of trained young men of 
talent and ability who will freshen the fabric 
of our knowledge and extend the benefits of the 
proper quality of medical service. 

Assurance of the availability of the means of 
training physicians should be one primary 
function of our organizational structure. If we 
hope to accomplish this, there must be formu- 
lated a sound long-range program of planning 
and execution. There is need for increased 
teaching facilities in subjects which relate to 
surgery of the colon and rectum. The curricula 
of most approved medical schools require 
revision. Clinical resources in hospitals and 
clinics associated with teaching institutions 
should be made available to medical students 
and interns. These facilities should be de- 
veloped in order to support laboratory and 
academic study. The establishment of more 
residencies in proctology is an important goal. 

It is important to extend the practice of 
preceptorship. In this method of education I 
fear we have procrastinated woefully. 

Man may consider himself superior in his 
ability to plan constructively for the future. 
He sows seed not only to satisfy immediate 
needs but also to grow additional seed for 
future harvests. It is not enough to hoard 
during one season like a squirrel which depends 
upon nature to supply the next crop of acorns 
and exercises no initiative on his part. Man 
alone is conscious of the practical and the 
mystic significance of keeping unbroken the 


eternally revolving cycle of sowing and reaping. 
The primordial certainty of a tomorrow, of 
another year, yes, even of an endless scries of 
future years, acts as a stimulant which urges 
us on to work beyond the point required for 
satisfaction of immediate needs. This belief is 
an inevitable future is one factor which is 
responsible for the prevalence of procrastina- 
tion. Some of us count on the certaintj' of time; 
we promise ourselves that we will modify our 
living by utilizing more discrimination and 
wisdom but at some later date. We may 
determine that we will study, dissect a cadaver, 
write a thesis or prepare for a Board examina- 
tion sometime when it is more convenient and 
thereby less effort may be required. Some of us 
have postponed the development of a clinic or 
a department. How many of us have interested 
ourselves in our younger men or have assisted 
and encouraged them in the practice of colonic 
and rectal surgery? How many of us in the 
exercise of our responsibility have made 
preceptorships available for the many eager 
and talented young surgeons who are turning 
with keen and inquiring minds to our special 
field? The har\'est of tomorrow is here today 
and procrastination never plowed a furrow or 
winnowed grain from chafl'. The needs of our 
successors for guidance and assistance are 
of the immediate moment and we must accept 
the obligation. The close personal relationship 
which existed between student and teacher 
and which was so fruitful during the period 
when such eminent teachers as Osier, Welch, 
Thayer and Halsted taught in Baltimore passed 
into oblivion when the demand for medical 
education assumed its present vast proportions. 
Nevertheless, the preceptor-student relation- 
ship still carries a high potential as a factor in 
medical education. The preceptor serves not 
only as teacher, as a sort of clearing house of 
knowledge and experience, but also as a whet- 
stone on which young men may sharpen their 
intelligence and their capabilities in scientific 
inquiry. With a profound sense of self-dedica- 
tion we must accept our responsibility in this 
connection. 

If the members of this Society expect to 
keep pace with the rapid developments in 
surgical science, there must be concerted action 
aimed at fostering research in all phases of 
colonic and rectal surgery. Research in the basic 
sciences must be inclusive. Without broad 
knowledge increased teaching facilities may 

American Journal of Surgery 



Presidential Address 


3 


soon disseminate the dust of outmoded 
thought; without more and better teaching 
facilities the results of research may never 
become available to professional practice. 
The two are linked inseparably. The students 
of today are the scientists, the teachers and the 
surgeons of tomorrow. 

In a world in which geographic boundaries 
have contracted and the means of communica- 
tion have been fabulously extended it would be 
folly to practice professional isolationism. To 
accept complacently the theory that we may 
occupy positions of leadership in medical 
discoveries, research and technics is to lay 
ourselves open to the danger of stagnation 
which is inherent in a spirit of self-satisfaction. 
It is fortunate that we have been able to 
receive, store and utilize a wealth of material 
which has been contributed by scientists from 
all parts of tlie world while other countries 
which formerly enjoyed a rich endowment in 
scientific accomplishment have been crippled 
or crushed by the disastrous conflict. We can 
well afford to be generous. Hoarding carries its 
own penalty through selfishness and resultant 
isolation while generosity brings well merited 
material and spiritual rewards. It is a laudable 
responsibility and a pleasant duty to be 
generous to our colleagues of the medical 
profession the world over. It is our gracious 
privilege to make available to them the 
facilities of our teaching and research centers. 

The importance of this international point 
of view cannot be emphasized too stronglj'. 
The medical profession by virtue of the char- 
acter of its work has the inestimable privilege 
of establishing good will and of promoting 
understanding among all the peoples of the 
world. Through such efforts suspicion may be 
allayed and confidence may be established. 
War-wrecked nations suffer not only bodily 


ills and a paucity of the means to correct them 
but psychic ills as well. Hunger, poverty and 
disease provide the soil for such conditions. 
Our effort to establish international amity will 
constitute an important factor in helping to 
restore the world patient to health. If in this 
process the patient can absorb an immunizing 
infusion against inimical ideologies and if faith 
and hope can be renewed, all humanity will be 
benefited. 

The American Proctologic Society is anxious 
to establish and to maintain a flow and an 
exchange of ideas with professional colleagues 
from other parts of the world. It would like to 
function as a central board of communication. 
It desires to serve as a source of whatever facts 
and skills it possesses and hopes to disperse 
them through medical journals and other means 
utilized for the dissemination of information. 

We hope that means can be provided which 
will permit and encourage visitors from other 
countries to visit our clinics and laboratories for 
the purpose of study and discussion. By such 
experience mutual benefits may be derived. 

Finally, I would urge consideration of the 
possibility of an organizational exchange of 
students. Intercommunication of thought is the 
wedge that holds open the door to the extension 
of knowledge and skill, to tolerance and under- 
standing. We cannot guard too carefull}’^ 
against a spirit of self-satisfaction and apathy 
as we observ’^e the needs and the achievements 
of others. 

In a world torn with uncertainties, conflicting 
ideologies and confusion, the medical profession 
will serve as a stabilizing influence by offering 
its own works, ethical principles and traditions 
as examples of tolerance, professional unselfish- 
ness and personal dedication to the highest 
ideals of humanity. 





January, ip$o 









FIRST FIFTY YEARS OF PROCTOLOGY 

JOSEPH M. MATHEWS ORATION 

Louis J. Hirschman, m.d. 

Detroit, Michigan 


I WISH to express to the membership of the 
American Proctologic Society my deep and 
humble appreciation on being selected to 
deliver this “Oration” to honor the “Father 
of American Proctology,” Joseph McDowell 
Mathews. To have the opportunity of speaking 
at this, the Golden Anniversary of the founding 
of the American Proctologic Society, is a dis- 
tinction which I believe was not properly 
merited. There are so many other Fellows of 
this organization who are far more gifted in the 
art of oratory and who could, undoubtedly, 
express in more eloquent language and beau- 
tifully turned phrases the thoughts which we 
all have in mind. 

Dr. Mathews was the first medical man on 
the continent and, so far as we have been able 
to learn, in the whole world to devote himself 
exclusively, to the practice of proctology. Up 
to the time, when upon his return from London 
in 1878 he announced to the profession his 
intention to devote his professional efforts to 
diseases of the rectum and colon, the treatment 
of rectal diseases, in particular, was largely in 
the hands of irregulars and charlatans. These 
men were following out the teachings of a 
Dr. Mitchell, who in 1871 first advocated the 
so-called injection treatment of hemorrhoids, 
utilizing a solution of phenol for that purpose. 
Joseph Mathews, therefore, was not only the 
pioneer proctologist but was actually the 
“Savior of Proctology.” 

When he was President of the American 
Medical Association in 1899, and incidentally 
was the youngest man ever elected to that 
office, he arranged for a dozen of his colleagues 
to meet with him to discuss the forming of. a 
national organization. These thirteen out- 
standing doctors of medicine, who were devot- 
ing either full or part time to the ethical 

January, ig^o 


practice of proetology, became the Founders of 
this Society. 

The American Proctologic Society was born 
in this city of Columbus, Ohio, on June 4, 1899. 
As a matter of record the names of the original 
Charter Members are as follows: 

Lewis H. Adler, Jr., Philadelphia, Pennsylvania 
William M. Beach, Pittsburgh, Pennsylvania 
George J. Cook, Indianapolis, Indiana 

A. Bennett Cooke, Nashville, Tennessee 
Samuel T. Earle, Baltimore, Maryland 
George B. Evans, Dayton, Ohio 
Samuel G. Gant, New York City 
Thomas C. Martin, Cleveland, Ohio 
Joseph M. Mathews, Louisville, Kentucky 
J. Rawson Pennington, Chicago, Illinois 

B. Merrill Ricketts, Cincinnati, Ohio 
Leon Straus, St. Louis, Missouri 
James P. Tuttle, New York City 

The meeting was called to order in the Chit- 
tenden Hotel under the temporary Chairman- 
ship of J. Rawson Pennington of Chicago. In 
this two-day session the various subjects in 
relation to our specialty were discussed and a 
constitution and bylaws were drawn up for the 
guidance of this infant organization. It is 
interesting to observe that the purposes of the 
American Proctologic Society were “The 
Cultivation and Dissemination of Knowledge 
in Whatever Relates to Diseases of the Rectum 
and Colon.” This was Article 1 1 of the original 
constitution. The foresightedness of these earlj'^ 
proctologists can be seen in the fact that even 
fifty years ago the majority of these men were 
already practicing the complete specialty of 
proctology which embraced the diagnosis and 
treatment of diseases of the rectum and colon; 
Proctology, even in those early days, which did 
not include the major diseases of the rectum 


5 




6 


Hirschnian — Joseph M. Mathews Oration 


and colon was not considered as the entire 
speciaItJ^ How well did they build! 

It must be remembered that all of these men 
came up the hard wai^ They were all general 
practitioners, most of whom had started prac- 
ticing in small communities and gravitated to 
larger centers. They then became general 
surgeons who realized that diseases of the 
rectum and colon were not receiving the proper 
attention they merited, so decided to limit 
themselves to the special study and treatment 
of those diseases. 

The first Officers of the American Proctologic 
Society were; 

President: Joseph M. Mathews of Louisville, 
Kentucky 

Vice-President: James P. Tuttle of New York 
City 

Secretary-Treasurer: William M. Beach of 
Pittsburgh, Pennsylvania 
These thirteen original Founders of the 
American Proctologic Society w'erc extremely 
reluctant to add to their numbers until they 
were sure, by careful investigation, that appli- 
cants for Fellowship were of high ethical, moral 
and professional standing in their own com- 
munities. There were, scattered about the 
nation, a number of unethical grail” o-^es of 
medicine who were advertising to the laity their 
skill in the diagnosis and treatment of diseases 
of the rectum and, particularly, without 
detention from business or hospital confine- 
ment. These w'ere the “ambulant proctolo- 
gists” who still flourish in far too great numbers 
even to the present day. 

Due to the careful scrutiny of the Society it 
took nearly another decade for it to double in 
membership. At the end of the first ten years 
there were thirty-one names on the roster. As 
a matter of record the full membership roster 
at the end of the first decade was as follows: 
Lewis H. Adler, Jr., Philadelphia, 

Pennsylvania C. M.* 

William M. Beach, Pittsburgh, Penn- 
sylvania _ C. M. 

George J. Cook, Indianapolis, Indiana C. M. 
A. Bennett Cooke, Nashville, Tennes- 


Samuel T. Earle, Baltimore, Maryland C. M. 
George B. Evans, Dayton, Ohio C. M. 

Samuel G. Gant, New York City C. M. 
^^omas C. Martin, Cleveland, Ohio C. M. 
M. Mathews, Louisville, Ken- 

C. M. 

’ Stands for Charter Member. 


J. Rawson Pennington, Chicago, Illi- 


nois C. M. 

B. Merrill Ricketts, Cincinnati, Ohio C. M. 

Leon Straus, St. Louis, Missouri C. M. 

James P. Tuttle, New York City C. M. 

Louis J. Krouse, Cincinnati, Ohio 1900 

Howard A. Kelly, Baltimore, Marj’’- 
land 1901 

John L. Jelks, Memphis, Tennessee 1902 

William L. Dickinson, Saginaw, Michi- 
gan 1902 

Thomas L. Hazzard, Pittsburgh, Penn- 
sylvania 1903 

Collier F. Martin, Philadelphia, Penn- 
sylvania 1904 

J. Coles Brick, Philadelphia, Pennsyl- 
vania 1904 

Dwight H. Murray, Syracuse, New 
York 1904 

T. Chittenden Hill, Boston, Massa- 
chusetts 1906 

Edward A. Hamilton, Columbus, Ohio 1906 
Louis J. Hirschman, Detroit, Michigan 1906 
Jerome M. Lynch, New York City 1907 
James A. MacMillan, Detroit, Michi- 
gan 1907 

J. A. McVeigh, Detroit, Michigan 1907 

George W. Combs, Indianapolis, In- 
diana 1908 

Alois B. Graham, Indianapolis, In- 
diana 1908 

Arthur Hebb, Baltimore, Maryland 1908 
Alfred J. Zobel, San Francisco, Cali- 
fornia ' 1908 


It is not my purpose to present a historical 
resume of the activities of the American Proc- 
tologic Society for the past half century; this 
will be done in a much more suitable manner bj' 
another Fellow. It happens that I am todaj'^ 
the oldest living Fellow in point of service if 
not in years. It is a privilege of old age to 
become reminiscent and, while the temptation 
to indulge in many anecdotes of a personal 
nature about many of our early Fellows is 
strong, I will limit myself to a few remarks 
about each of our original thirteen Founders 
who, like the thirteen original Colonies of our 
Nation, declared their Independence of the 
specialty of general surgery and created the 
then new specialty of proctology. 

As a reminiscent oldster, it will be necessary 
to speak in the first person singular. I hope that 
my audience will forgive me for this but be- 
cause of my acquaintanceship and contact with 
all of the Charter Members, I am taking advan- 

American Journal oj Surgery 



Hirschman — Joseph M. Mathews Oration 


7 


tage of this fact to give this presentation 
a more personal touch. I will mention these 
men, not necessarily in the order of their 
prominence or importance in our profession, 
but alphabetically: 

Lewis H. Adler, Jr., M.D., Philadelphia, Pennsyl- 
vaiiia. Born in Philadelphia in 1864, Dr. Adler 
was a meticulous, kindly and precise individual, 
the worthy son of a worthy father. He was probably 
the first physician to limit himself, on a highly 
ethical plane, to the practice of proctology in the 
City of Brotherly Love. He served as President 
of the society in 1905 and as Secretary-Treasurer 
from 1907 to 1913, which was the longest term that 
any Secretary-Treasurer has served before or 
since. He was active in all of the society’s deliber- 
ations and was a marvelous host to any of the 
Fellows who visited Philadelphia. He passed away 
in 1934. A short time before his death he became 
annoyed with certain decisions made by the 
society, regarding the increase in membership and 
so withdrew from active participation. In order to 
show his good will he presented a check for a 
generous amount to be used as an Honorarium to 
stimulate the interest of younger men in proctologic 
subjects. He was never interested in diseases of 
the colon or colonic surgery. 

William M. Beach, M.D., Pittsburgh, Pennsyl- 
vania. Dr. Beach was a rotund, kindly gentleman, 
who in his early days wore a beard so that his 
resemblance to King Edward vii, of Great Britain, 
was so strong as to cause comment whenever he 
appeared in public. In spite of his girth Dr. Beach 
was an extremely active individual who loved all 
the good things to eat and who loved to serve them 
to others. However, his Scotch ancestry came to 
the surface when it came to paying the check and 
he was the recipient of much good natured ribbing 
on that account. Dr. Beach served as the first 
Secretary of the society and continued in that 
office until 1903, when he was succeeded by Dr. 
Cooke. Dr. Beach was raised to the Presidency 
following his efficient handling of the Secretary’s 
office. He was ingenious in the devising of methods 
and instruments, which were very useful and one 
of the first good sigmoidoscopes was invented by 
him. Dr. Beach died in 1930. 

George J. Cook, M.D., Indianapolis, Indiana. 
Dr. Cook was born in Pennsylvania in 1844. He 
was one of the early ethical American proctolo- 
gists; in fact, it was always interesting to hear him 
argue with Dr. Joseph Mathews as to who was 
really the “Pioneer Proctologist.’’ They were warm 
personal friends and great mutual admirers. Dr. 
Cook was eccentric in some ways, never liked to 
speak in public because of a slight speech defect. 
He was active in his local County College and 
State Medical affairs and served as Secretary of 
the Indiana Medical College for nearly twenty 

January, 1950 


years. He was widely sought after for his kindlj' 
counsel and especially endeared himself to the 
younger men who were interested in proctology. 
His tri-valve rectal speculum was widely used in 
the days when general anesthesia was employed in 
rectal surgery. He was President of the Proctologic 
Society in 1910 and died in 1920. 

A. Bennett Cooke, M.D., formerly of Nashville, 
Tennessee. Dr. Cooke was born in 1853. He was 
anything but a typical Southerner in his activities 
and speech. He had many of the so-called eccen- 
tricities and kinetic drive of a “Damyankee.” He 
was an extremely argumentative individual and 
unsparing critic. He was very thin; in fact, he was 
occasionally addressed as “The Lean and Hungry 
Cassius.” He was the author of one of the early 
textbooks on Diseases of the Anus and Rectum, 
and served as Secretary of the Society 101904-1906 
when I first applied for Fellowship. He served in 
that capacity until he was succeeded in 1907 by 
Dr. Adler and was elevated to the Presidency in 
that year. Dr. Cooke, subsequently, moved to Los 
Angeles where he re-entered the practice of general 
surgery and built up a splendid clientele. He was 
connected with some of the leading hospitals and 
practiced actively until the time of his retirement 
a few years ago. His death in 1946, at the ripe old 
age of ninety-three, marked the passing of the last 
of our Charter Members and Founders. 

Samuel T. Earle, M.D., Baltimore, Maryland. 
Dr. Earle was born in Maryland in 1849 and was 
one of the old stalwarts; he was a soft spoken 
Southern gentleman, tall and spare in stature, light 
in weight but strong in opinions, even though very 
gently expressed. He was the first Professor of 
Proctology at the University of Maryland and 
occupied that chair until his death. He was an 
ardent student of medical literature, and personally 
presented the first review on this subject before the 
Society. He served for many years on the Maryland 
State Board of Health and occupied many positions 
of responsibility, including the Presidency of his 
State Society. He wrote an exhaustive textbook 
on Diseases of the Anus, Rectum and Pelvic Colon 
which was published in 1911. He died in 1931. 

George B. Evans, M.D., Dayton, Ohio. Dr. 
Evans was born in 1854 and started out in general 
country practice. After moving to Dayton he 
limited his practice to gynecology as well as 
proctology. He was a high Mason and had a large 
circle of friends both in and out of the profession 
and enjoyed a lucrative practice. He was a serious, 
earnest, hard-working individual; and in spite of 
the fact that he had located in a city, which did not 
possess a Medical School, he kept well abreast 
of medical problems and devoted a great deal of 
time and effort to instructing his interns in proc- 
tology. He believed that perineal proctectomy was 
the operation of choice in rectal cancer surgery and 
advocated the preservation of as much^'of the 



8 


Hirschman — Joseph M. Mathews Oration 


levator muscles as possible. He believed that 
these muscles, when sutured to the bowel, acted as 
a third sphincter. The problem of lateral or down- 
ward lymphatic spread never seemed to bother 
him. He was a kindly, genial gentleman and a loyal 
friend and was one of the three proctologists to be 
elected to the Office of Vice-President of the 
American Medical Association. Formerly the Vice- 
President served as Presiding Officer of the House 
of Delegates; and it so happened that at the 
Detroit meeting in 1915 Dr. Evans was in the 
Chair when I, as a Delegate, moved that a Section 
on Proctology be established by the American 
Medical Association. This was the formal action 
which resulted in the establishment of the Section 
on Gastroenterology and Proctology, which held 
its first session in New York in 1917. Dr. Evans 
died in Dayton in 1930. 

Samuel G. Gant, M.D., New York, N.Y. Dr. 
Gant who served as our President in 1906-1907 
will be remembered by many of our present mem- 
bership because he was a regular attendant at our 
meetings until the year of his death which occurred 
in 1944. Dr. Gant was born in Missouri, as were 
several of our other Charter Members, and prac- 
ticed proctology in Wichita, Kansas, and Kansas 
City, Missouri, before being invited to take over 
the Professorship of Proctology at the New York 
Post-Graduate School. He used to relate, with 
various embellishments, how he was invited to 
write his first book on rectal diseases. It seems that 
a medical book salesman called upon him in 
Kansas City and happened to mention the fact 
that the publisher whom he represented was 
suffering from hemorrhoids. Dr. Gant sold the 
idea to the salesman that he was a very good 
proctologist and subsequently operated upon the 
boss. The publisher was so well satisfied he insisted 
that Dr. Gant write this book, which he did. Dr. 
Gant states that this was what led to the invitation 
to the Professorship in Proctology in New York. 
Dr. Gant afterward wrote several other volumes 
on the subject and contributed many papers to 
various State and National medical meetings. He 
was one of the first proctologists to advocate the 
use of local anesthesia in rectal surgery and gained 
quite a little prominence from his advocacy of the 
use of sterile water alone as an anesthetic agent. 
We all remember Sam Gant as a handsome, 
debonair, jolly raconteur and no meeting was 
complete without a performance in legerdemain 
by Dr. Gant. I have been told by professional 
magicians that he ranked very high in this field. 
He was a member of the famous Lambs’ Club of 
New York, whose membership was composed of 
^''^fcssional theatrical people. While in his latter 
he lived in a state of semi-retirement, he 
Sam^ managed to appear at our annual meetings. 

v^as the last of our Founders, but one, to 


pass away and his charming pcrsonalitj' will long 
be missed by all. 

Thomas Charles Martin, M.D., Cleveland, Ohio. 
He was one of the first proctologists to practice in 
Cleveland, Ohio, and was President of the Society 
in 1901-1902. He used to keep all of the oldsters 
puzzled with new names which he invented for 
many of his procedures and instruments. He was 
the first to emphasize and publicize the so-called 
important factor in constipation presented by 
enlargement and fibrosis of the valves of Houston. 
Like all enthusiasts he went to extremes in this 
matter. Dr. Gant very soon followed in his foot- 
steps as did Dr. Pennington; more will be said 
about this matter in connection with Dr. Penning- 
ton. Dr. Martin was another devotee of Beau 
Brummel, he was an example of sartorial elegance 
and was extremely polished and gentlemanly in his 
conduct with others. A few years before his death 
he moved to Washington, D. C., where he quickly 
acquired a large clientele. He resigned from the 
Society on account of ill health and for several 
years was not active. He died in Washington in 
1926. 

Joseph McDoivell Matheivs, M.D., Louisville, 
Kentucky. Dr. Mathews who is recognized as the 
“Father of Proctology” both in this country and 
abroad was born in Kentucky in 1847. He gradu- 
ated in medicine from the University School of 
Medicine at Louisville in 1867 and returned to his 
birthplace to practice general medicine, where he 
remained until 1872, He continued general practice 
in Louisville until 1878. Becoming very much 
interested in diagnosis and treatment of rectal 
diseases, he went to London and served with the 
late William Allingham who was, at that time, 
Senior-Surgeon of St. Mark’s Hospital. On return- 
ing to Louisville he entered the full-time practice 
of proctology. He became lecturer on diseases of 
the rectum and colon at the Hospital College of 
Medicine in Louisville and was also Professor of 
Surgery in the Kentucky School of Medicine, 
where he held a clinic on diseases of the rectum and 
colon. During his busy life he occupied many 
important public positions, many of which will not 
be listed here for lack of space. He was elected 
President of practically all of the organizations of 
which he was a member. He was the first proc- 
tologist to be elected to the Vice-Presidency of the 
American Medical Association and was advanced 
to the Presidency in 1899, being the youngest man 
up to that time ever elected to that office. He was 
a prolific writer and in addition to his well known 
treatise on “Diseases of the Rectum and Colon” 
he also wrote a popular book entitled “How to 
Succeed in the Practice of Medicine.” He was con- 
nected, in an editorial capacity, with the “Medical 
Herald” and “Medical Progress.” For several 
years he published “Mathews’ Medical Quar- 
terly which was the first journal devoted entirely 

American Journal of Surgery 



Hirschman — Joseph M. Mathews Oration 


9 


to the specialty of proctology. Dr. Mathews was 
one of the finest orators in the medical profession. 
He was considered a great orator in his home state 
of Kentucky, which is the home of great orators. I 
can recall, with great pleasure, being one of a circle 
in his hotel apartment at many of the early meet- 
ings of the American Proctologic Society, where 
“Uncle Joe” kept his audience convulsed with his 
humerous anecdotes of his early life and his 
southern stories. There was always a liberal supply 
of bourbon on .hand and conviviality, congeniality 
and hospitality were at a high level. When Presi- 
dent Cleveland was in office he seriously considered 
appointing Dr. Mathews as Surgeon General of the 
Public Health Service. Dr. Mathews often re- 
marked that he was very happy that he did not 
receive that appointment. He retired from active 
practice of medicine in 1913 and moved from 
Louisville to Seattle where he and Mrs. Mathews 
resided for four years. They then took up their 
residence in Los Angeles where Dr. Mathews died 
in 1928, and Mrs. Mathews followed him nineteen 
days later. 

John Rawson Pennington, M.D., Chicago, Illinois. 
Born in Indiana in 1856, Dr. Pennington was one 
of the most indefatigable workers in our specialty. 
He was the first ethical physician really to make 
Chicago proctology conscious. After his graduation 
from the University of Maryland in 1887 he prac- 
ticed in Kentucky receiving an honorary degree of 
M.D. in 1892. The next year he went to London 
where he spent some time in special study at 
St. Mark’s Hospital. He limited himself to the 
practice of proctology from that time until his 
death. He had many hospital affiliations and was 
Professor of Rectal Surgery at Chicago Polyclinic 
and later Professor in the Illinois Post-Graduate 
School of Medicine. He was the Charter Member 
who was temporary Chairman at the organization 
meeting at Columbus in 1899 and in 1904 became 
President. In 1922 he was elected Chairman of the 
' Section on Gastroenterology and Proctology of the 
American Medical Association. Dr. Pennington 
was a man of strong likes and dislikes and was a 
loyal friend and critic. He was a mechanical genius 
and developed many instruments for the diagnosis 
and treatment of diseases of the rectum and colon. 
He was one of the first proctologists to break away 
from the clamp and cautery type of operation and 
also criticized the use of too many sutures in ano- 
rectal surgery. He will be remembered by some of 
the older men for his harsh discussions of ideas of 
men, with whom he did not agree, but after the 
session would be the first to shake hands, slap their 
back and have a convivial drink with his erstwhile 
opponent. Sometimes his hot temper got the 
better of him. Those of us who witnessed the 
incident at the Chicago meeting in 1907 will 
remember his sharp controversy with the late Leon 
Straus of St. Louis at the Palmer House, on the 

January, ig^o 


subject of “Valvotomy and Valvotomists.” Dr. 
Straus, who was also somewhat quick-tempered, 
made a critical remark about the Pennington clamp 
whereupon Pennington stepped up and with a 
well directed blow, which might have done credit 
to Joe Louis, knocked Straus to the floor where he 
took the count. Dr. Pennington was the first to 
help Dr. Straus to his feet and with tears in his 
eyes begged forgiveness. If Dr. Pennington had 
done nothing else for proctology but to call atten- 
tion to the extreme importance of the anal canal as 
a focus of infection, as illustrated by his remarkable 
diagram “The Somatic Funnel” in his magnificent 
work “Treatises on the Diseases and Injuries of the 
Anus, Rectum and Pelvic Colon” published in 
1923, he earned a place in our “Hall of Fame.” 
This volume is still considered by many as the 
best compilation of proctology from the historical 
standpoint that has ever been published. It still is a 
Proctologic Encyclopedia. He died in Chicago of a 
coronary thrombosis in 1927. 

B. Merrill Ricketts, M.D., Cincinnati, Ohio. 
Although one of the Charter Members and 
Founders of our organization. Dr. Ricketts’ con- 
nection with the American Proctologic Society was 
rather brief. He was a gynecologist and abdominal 
surgeon connected with the University of Cin- 
cinnati and had a large following among the 
profession in the territory surrounding Cincinnati. 
He appeared but once on the program and rarely 
took part in the discussions. He died about the year 
1910. 

Leon Straus, M.D., St. Louis, Missouri. Dr. 
Straus along with Dr. Tuttle were the first two 
Charter Members who limited themselves to proc- 
tology, to pass away. Dr. Straus was born in 
Kentucky in 1861 and graduated from the Uni- 
versity of Louisiana in 1879. After a few years of 
general practice he entered the office of Joseph M. 
Mathews, where he remained as his assistant for 
several years. On the advice of Dr. Mathews he 
moved to St. Louis, Missouri, where he engaged in 
the private practice of proctology. He enjoyed a 
large clientele and was well liked by his professional 
confreres, in spite of the fact that he had a rather 
hasty temper and at times his southern blood 
would boil over, as it did in the case of the argu- 
ment with Dr. Pennington on “Valvotomy and 
Valvotomists.” He was a regular attendant at the 
meetings of the Proctologic Society and con- 
tributed freely to the program both in papers and 
discussions. He died suddenly of a coronary attack 
in St. Louis in 1913. 

James P. Tuttle, M.D., New York, New York. 
The year 1913 was a sad one in the history of our 
Society. In that year we sustained the loss by death 
of two valued Charter Members, Drs. Tuttle and 
Leon Straus of St. Louis. Dr. Tuttle was the tem- 
porary Chairman at the organization meeting here 
in 1899, and was elected Vice-President, advancing 



10 


Hirschman— Joseph M. Mathews Oration 


to the Presidency in the year 1900. Ho was another 
proctologist born in the State of Missouri, this 
event occurring in 1857. He established the chair 
of Proctology at the New York Polyclinic Hospital 
in 1893 and was consulting surgeon to many other 
hospitals in that city. Those who were fortunate 
enough to know Dr. Tuttle, and his friends both 
inside and outside of the profession were legion, 
could not help but admire his sterling honesty, 
probity and tremendous interest in the develop- 
ment of our specialty. Many proctologists through- 
out the country can attribute their first interest in 
our specialty to their contact with Dr. Tuttle at the 
Polyclinic in New York. While a very serious 
minded individual, he had a rare sense of humor; 
one could see a good story bubbling up as from a 
spring, by the twinkle in his eye and the gradually 
developing smile on his otherwise austere counte- 
nance. His monumental book on ‘‘Diseases of the 
Anus, Rectum and Pelvic Colon” published in 1902 
still stands as one of the greatest volumes ever 
published and was looked upon as a bible by manj' 
proctologists as well as general surgeons. It was mj' 
good fortune to know him quite intimately and to 
be a guest at his home and have him as a guest at 
mine. Both he and his wife were ideal hosts and 
made one feel that he was one of the family. In 
spite of the fact that Dr. Tuttle suffered in his 
latter years from diabetes and insomnia, he never 
faltered in his clinical teachings and his service to a 
large private clientele. His death marked the first 
break in the ranks of our Founders, creating a void 
which has never been completely filled. 

The last of our Charter Members has an- 
swered the final roll-call; If we look over the 
membership roster of the American Proctologic 
Society, we cannot but feel proud and thrilled 
at the deep respect and high esteem in which 
many of our fellow proctologists have been held 
by the profession in general. National, State, 
County and Special Societies have honored 
many of our men, and more of our Fellows still 
have other well deserved rewards awaiting them 
in the future. 

Joseph M. Mathews, of course, was the first 
and only proctologist to date who has been 
honored by the Presidency of the American 
Medical Association. However, he and two 
other proctologists have served as Vice- 
Presidents of the American Medical Associa- 
tion. One of our members was chosen, in the 
early years of the House of Delegates, as its 
Speaker and officiated until his sudden death. 
Ten of our proctologists have served as 
Presidents of their State Medical Societies; in 
three of these Societies two proctologists have 
been chosen to serve as President. Several 


proctologists have served on their State Boards 
of Health and in at least three instances to my 
persona! knowledge they have served as 
President. At least two of our proctologists 
have served on the important Judicial Council 
of the American Medical Association. Many, of 
course, have acted as Delegates to the American 
Medical Association as well as to State Houses 
of Delegates; and innumerable proctologists 
have been called to serve as Councilors of their 
State organizations. A large number of proc- 
tologists have served as Presidents and Secre- 
taries of their County Medical Societies. I 
could go on and list many other honors, some of 
a political as well as a professional nature, which 
have come to members of our specialty. 

The increasing recognition by Universities 
and Medical Schools of our specialty is gratify- 
ing. A goodly number of Class A Medical 
Colleges are having proctologists teach proc- 
tology to undergraduate students and many 
others are providing for post-graduate teach- 
ing in proctology as well. There are a number 
of fulltime professorships in proctologj" in our 
better medical institutions; and it is up to the 
present membership to increase this number. 
The teaching of proctologj’- to both under- ' 
graduate and post-graduate students along 
with the further development of internships 
and particularly residencies in proctology is an 
important field of endeavor for the present and 
future membership of our Society. 

If one looks back over the past fifty-years, a 
number of achievements in the progress and 
development of our specialty loom above the 
already high level of accomplishment. In order 
not to draw this presentation to an unseemly 
length, I will mention but four outstanding ' 
epochs in the progress of American Proctology 
as initiated, developed and consummated 
the American Proctologic Society. 

The first epoch was marked by the publica- 
tion of the complete transactions in book form 
in 1908. At that time it was believed that 
proctology, having come into its own as a 
specialty, should receive more national recog- 
nition, so application was made tc join the 
American Congress of Medicine. This Congress 
was composed of the representative national 
societies of each of the specialties. They met 
every three years as a group in Washington, 

D. C., and in the intervening years at various 
other centers. One of the qualifications for 
membership in this Congress was the annual 

American Journal of Surgery 


Hirschman — Joseph M. Mathews Oration 


publication in book form of papers presented 
before a society for the three years previous to 
its application. Unfortunately, by the time we 
had qualified for admission to the Congress it 
no longer existed. The publication of the trans- 
actions, however, has continued without inter- 
ruption since that time. 

The second epoch was the movement for the 
establishment of a Section on Proctology in 
the American Medical Association. This was 
first suggested officially by A. Bennett Cooke 
in his Presidential Address in 1910. Between 
that time and 1913, when I happened to be 
President of the Society, we conducted a cam- 
paign to secure signatures to petitions to the 
House of Delegates of the American Medical 
Association for the creation of a Section. At the 
Minneapolis meeting of the American Medical 
Association in 1913 I appeared with J. Rawson 
Pennington and Dwight H. Murray before the 
Committee on Sections and Section Work and 
secured a temporary authorization for the 
formation of the Section. There was a string 
tied to it, however, and that was that the 
American Proctologic Society and the Ameri- 
can Gastroenterologic Society should disband. 
The American Proctologic Society was willing 
to commit "hari-kari” for the good of the 
cause, but the gastroenterologists refused to do 
likewise; so it took another period of maneuver- 
ing until, finally, at the Detroit meeting in 
1915, with one of our Charter Members, 
George B. Evans, Vice-President of the 
American Medical Association, in the Chair, I 
introduced a resolution in the House of Dele- 
gates to create our Section. As a compromise, 
however, we were forced to combine with the 
gastroenterologists and our Section was born. 
At the first session held in New York in June, 
1917, a large and enthusiastic gathering was 
present. Military uniforms were conspicuous 
throughout the large audience as we had just 
entered World War i. As a matter of record it 
should be noted that the first Chairman of this 
Section was Dwight H. Murray and I served 
as its first Secretary. 

The third epoch in the history of our Society 
was the celebration of our Silver Anniversar}' 
in 1924 by a joint meeting with the Section of 
Proctology of the Royal Society of Medicine 
in London, England. Fourteen of us, accom- 
panied by our wives, made this pilgrimage and 
I can assure you all that it turned out to be a 
glorious occasion. It meant the creation and 

January, ipjo 


1 1 

cementing of friendships between those indi- 
viduals who represented the two proctologic 
organizations of the English speaking world. 
Although it took another quarter of a eenturj' 
for a joint meeting, we all feel very happy and 
overjoyed bj^ the presence of our British 
colleagues to help us celebrate our Golden 
Anniversary. 

The fourth epoch was the hard, gruelling 
uphill labor to secure Certification of Proc- 
tology as a recognized Specialty. Following the 
suggestion of Curtice Rosser in his Presidential 
Address at Chicago in 1933, a small group of us 
appeared before the representatives of the four 
Specialty Boards then organized and function- 
ing. This group composed the Advisory Council 
on Medical Specialties in 1933. After making 
our presentation we were advised to proceed 
with the incorporation of our Board but to 
await the formation of the American Board of 
Surgery before seeking further recognition. We 
graciously stepped aside, but in the meantime 
had adopted a constitution and bylaws and had 
secured our incorporation in the State of 
Delaware in 1935. After many heart-breaking 
experiences and repeated appearances before 
the Advisory Council on Medical Specialties 
and the more sympathetic Council on Medical 
Education of the American Medical Associa- 
tion, we finally secured recognition in 1940 bj’’ 
the formation of the Central Certifying Com- 
mittee in Proctology, functioning under the 
American Board of Surgery. This has made a 
superspecialty of proctology as a candidate has 
to qualify by submitting to the same exami- 
nation as a candidate for general surgical 
certification before being allowed to take the 
examination in proctology. We are still fighting 
for independence. At the February meeting of 
the Advisory Council on Medical Specialties 
and the Council on Medical Education in 
Chicago, the American Board of Proctology, 
was recognized for the first time as a Certifying 
Board. We are to act as an Affiliate Board of 
the American Board of Surgery, unless that 
Board refuses to meet certain conditions laid 
down by the above named Councils. If the 
American Board of Surgery refuses, we are then 
authorized to act as an independent Certifying 
Board.* 

* On June 15, 1949, the American Board of Proc- 
tology was authorized by the Council on Medical 
Education and Hospitals and the Advisory Board for 
Medical Specialties to function as an independent 
examining board. 



12 


Hlrschman — Joseph M. Mathews Oration 


It has been a source of great personal satis- 
faction to me as tlie senior surviving Fellow to 
be able to transmit to those of you who are now 
carrying on the persistent progress of proc- 
tology, these impressions of personal contact 
with all of our Founders. 

The original thirteen Charter Members were 
hesitant and cautious about enlarging their 
group. When I was accepted for Fellowship in 
1906, two others whose names also happened 
to begin with “H,” namel}', Hamilton of 
Columbus and Hill of Boston were also ac- 
cepted. No more than three applieants had 
been accepted in any one year up to that time. 

“From This Small Acorn a Great Oak Has 
Grown”! From a membership of thirteen the 
American Proctologic Society has developed 
over the past half century until at present there 
are on the membership roll 400 proctologists, 
with about eighty applications on file. This 
number included all classes of membership and 
in the junior group we have an abundance of 
the finest type of material, so those of us who 
have labored long in the vineyard can rest 


assured that the future of proctologj' is in 
competent hands. We know that the fine 
younger generation of well trained proctolo- 
gists, who are now coming into the Socictj', will 
continue to carry on the torch. 

The American public as well as the profession 
have created a demand for the highly special- 
ized care of diseases of the rectum and colon 
which only the qualified proctologist can 
render. 

With the establishment of an independent 
Board of Proctology as a member of the 
Advisory Council on Medical Specialties, proc- 
tology will occupj’' its proper place in the sun. 

Those of us who have assisted in the develop- 
ment of the specialt}' through the American 
Proctologic Society can rest happy in the 
knowledge that the proctologic patient of the 
future will continue to receive that scientific, 
personal, kindly and humane care to which 
they are so justly entitled. 

All Hail and Godspeed to you my Comrades! 
To your hands is entrusted the future progress, 
development and glory of American ProctologJ^ 




American Journal oj Surgery 



HISTORY OF THE PROCTOLOGIC SECTION OF THE 
ROYAL SOCIETY OF MEDICINE 

A. Hedley Whyte d.s.o., t.d., m.b., m.s., f.r.c.s. 


Newcastle-upon-Tyne, England 


M an has always been curious. A desire 
to learn is an essential part of his 
intellectual make-up. Through the 
ages we can trace a continuous striving to 
satisfy this desire. Early attempts may seem 
to us rather childish, the transmission of knowl- 
edge being merely the answering of questions 
then, of course, mostly incorrectly; but we 
appreciate the fulfillment of some of our 
intellectual strivings in a Society such as yours 
is. In Ancient Greece and Rome the word of a 
master was passed on by his pupils to a wider 
circle. We read of the dogmatists, the emperics, 
the Methodists, the pneumaticists, and the 
eclectics. With the exception of Hippocrates, 
Aristotle and Galen knowledge was passed on 
by word of mouth but, of course, there was no 
observation of facts and no experimentation. 

Early in the seventeenth century societies as 
we understand them began in Italy. In 1603 
Prince Cosi founded the Accademia dei Lincei 
in Rome. Fifty years later our Royal Society 
was formed. They always received communica- 
tions from medical men as well as from those 
engaged in other branches of natural science. 
The Accademia del Cemento was established 
in Florence in 1657 and it included medicine as 
one of its branches. 

By royal edict of Louis xv who acted upon 
the recommendation of his surgeons the Royal 
Academy of Surgerj'^ was formed in Paris. Its 
first meeting was held on December 24, 1731. 
It was suppressed in 1793 during the Revolu- 
tion “when France had no need for science”; it 
came to life again, however, as the Societe 
Nationale de Chirurgie and since 1820 as the 
Acadamie de Medicine. 

Medical Societies in Great Britain began 
about the middle of the eighteenth century as 
the direct result of a desire for a better educa- 
tion than was given by the older and privileged 
lieencing bodies. 

In London our Royal Society of Medicine, of 
which the Proctological Section is such a flour- 
ishing and, we think, important part, was a 

January, iQ^o 


direct descendant of the Royal Medical and 
Chirurgical Society of London. 

In 1518 Linacre had founded the College of 
Physicians. The College of Physicians played 
an important part in the foundation of the 
Royal Society and in the rise and advancement 
of the London societies in the eighteenth cen- 
tury. The greatest of these societies was the 
present Medical Society of London which was 
founded in 1774. 

We read that from 1786 onward for twenty- 
two years the Medical Society of London had 
only one President, Dr. James Sims. Certain 
of its fellows found his rule intolerably irksome 
and in May, 1805, at a meeting held at the Free 
Masons Tavern the Royal Medical and Chirur- 
gical Society of London was founded. Through- 
out the second part of May and the early part 
of June committee meetings were held and the 
first general meeting took place on June 14th 
at the Free Masons Tavern. The second Meet- 
ing was held on June 28th at the Crown and 
Anchor in the Strand. The original business 
of the Society was to converse upon profes- 
sional subjects and to read and hear letters, 
reports and other papers on Medicine or any 
of its branches. An extensive and select 
professional library was collected. First meet- 
ings were held at the Crown and Anchor 
Tavern. A subcommittee was immediately 
formed to inquire concerning a proper house 
for the work of the Society and eligible apart- 
ments were found at 2, Verulam Buildings, 
Gray’s Inn. This was to be the home of the 
Society for five years. Verulam Buildings was 
built in 1803 and it still stands practically 
unchanged although there was considerable 
bombing during the war of the neighborhood 
and much damage was done. The old lantern 
at the front door and one of the railings have 
gone but it is presumed that these are from the 
ravages of time and not the result of enemy 
action. 

The first meeting was held on December 1 8, 
1805; Dr. Saunders, the first President, gave 


13 



'.4 


Whyte — Royal Society of Medicine 


an Address on the “Eight Objects of the 
Society and tlic Best Means of Carrying tlicni 
into Effect.” Early papers read included “Case 
of Aneurism of the Carotid Artery ” by Astley 
Cooper, Surgeon to Guy’s Hospital, and one 
on “A Diminution in Consequence of Disease, 
of the Area of the Aperture by which the Left 
Auricle of the Heart Communicates witli tlie 
Ventricle of the Same Side” by John Abcr- 
ncthy, Assistant Surgeon to St. Bartliolomcw’s 
Hospital. Papers were not always read; certain 
evenings were given over to conversation. On 
May 27, 1807, one topic for discussion was 
“Stricture of the Rectum.” The year 1808 
seems to have been a poor one; even the 
President, Dr. Saunders, did not bother to 
turn up at the five meetings before the Annual 
General Meeting but the Library soon grew 
to some 400 or 500 volumes. A movement was 
afoot at that time to amalgamate the Royal 
Medical and Chirurgical Sccicty with the 
Medical Society of London but nothing came 
of it. 

In 1809 the first volume of Trans.actions was 
published. In 1810 the Society moved to 
Lincoln’s Inn Fields and kept house at No. 3 
with the Geological Society. Number 3 is on 
the north side of the Square facing the Royal 
College of Surgeons which had obtained its 
Royal Charter in 1800. 

In 1812 an attempt was made to obtain a 
Charter for itself but this was opposed by the 
Royal College of Physicians. There was some 
question of sharp practice in connection with 
the obtaining of signatures to a memorial to 
the Privy Council. 

The Medical and Chirurgical Society was 
growing; in 1815 the Geological Society moved 
to Russell Square. Four years later when 
Astley Cooper was President the Medical 
Chirurgical Society also moved and a new home 
was made at 30, Lincoln’s Inn Fields. This was 
only to be a short resting place and in the 
following year still another move was made to 
No. 57. At that time the attendance at meetings 
fell off because of the death of His Majestj' 
King George in and few interesting papers 
were read. In one an account is given of a stone 
weighing 9 ounces which was removed through 
the rectum as the suprapubic operation was 
said to have become obsolete. 

The Society remained at No. 57 ^he West 
side of Lincoln’s Inn Fields for fourteen years. 
The house was shared with the Astronomical 
Society, who seemed to have occupied an attic 


only, and had the occasional use of other 
rooms. From time to time various other tenants 
occupied different parts of the house. For the 
first few years all went well and then there 
came a sort of depression. What the cause of 
this depression was is rather dilficult to ascer- 
tain. We read of the wearisome length of some 
of the papers but more likely the center of 
gravity of consulting practice was moving west 
and away from the Society’s headquarters. 

Lincoln’s Inn Fields was no longer central 
and Bedford Row and Great Coram Street 
were no longer popular. Eventually in 1834 a 
move was made to 53, Berners Street (Fig. i), 
which was to remain the home of the Society 
for many years, in fact, until 1890 when another 
move was made to 20, Hanover Square. (Fig. 
2.) Today the upper three stories of No. 53 
remain completely as they were when occupied 
bj' the Society but the building is occupied by 
a firm of wholesale wallpaper manufacturers 
and the ground door is a shop front. Number 
20, Hanover Square is unaltered save for the 
fact that the railings and trees immediately in 
front of the house have gone and the house is 
occupied by the well known real estate agents, 
Frank, Knight and Rutley. 

The move west to Berners Street was a 
stimulus to the Society and meetings were 
better attended. In 1836 Burne contributed a 
paper of great historical value on “Diseases 
of the Caecum and Appendi.v Vermiformis.” 
In 1839 Sir Benjamin Brodie was elected 
President. Ne.xt year Her Majesty Queen 
Victoria became Patroness. The Society con- 
tinued to flourish and the meetings were well 
attended. It is interesting to note in 1845 that 
a Dr. Merriman presented an “Index Medicus” 
of various medical journals and Evans recorded 
a case of “Lumbar Colotomy, Callisen’s Oper- 
ation, modified by Amussat.” This was appar- 
ently the eleventh case to be recorded. 

Also in that year we read of the somewhat 
heroic, apparently successful treatment of a 
patient with tetanus, with two gallons of 
brandy in eight days, besides wine. The dis- 
appearance in another case of hard circum- 
scribed tumors in muscle under the influence of 
Iodide of Potassium is described. 

In 1848 mention of anesthetics is noted in 
the case records. 

In 1850 the Pathological Society wished to 
become joint tenants at 53, Berners Street, but 
it was thought that the “Exhibition of many " 

American Journal 0/ Surgery 


Whyte — Royal Society of Medicine 


15 


recent specimens would probably create a 
nuisance.” 

The year 1851 seems to have been a great 
one. The average attendance at meetings was 
about 1 1 0 and many papers were read and 
published. A case of interest was Juke’s 


never been regarded as a right to practice any 
branch of medicine, even within the precincts 
of the University of Cambridge.” 

In that year Cock read a paper on the 
“Operation Usually Adopted for Retention of 
Urine: with Special Reference to Puncture 



Fig. I. No. 53, Berners Street, London, England. 


inguinal colotomy, one of the first records of 
Littre’s operation in England. 

In 1852 Dr. Benker, Physician to St. 
Thomas’s Hospital, was very angrj^ that a 
candidate was up for election whose only 
stated qualification was the m.b. of Cambridge. 
That degree, he said, “does not constitute him 
either a Physician, Surgeon or General Prac- 
titioner. It does not profess to be, and has 

Januar\,r, ipyo 


through the Rectum.” Papers on colotomy 
were read by Hawkins, Adams, Clements and 
Baker. Clements says (October, 1841) of one 
of his operations, a right lumbar colotomy: “I 
believe this operation was the first performed 
in England according to the directions of 
Mons. Amussat. Mr. Teale of Leeds performed 
the second, and the late Mr. Jukes of Birming- 
ham the third.” 




i6 


Whyte — Royal Society of Medicine 


. 'In, i860 Curling read a paper entitled “Im- cases in all recorded by him. He pointed out 
perforate Anus with Analysis of 100 Cases.” that one great merit of the antiseptic system 

The year 1873 was notable for a paper by was that the intraperitoneal method was the 
Burdon Sanderson on the infective products of more successful method of dealing with the 
acute inflammation. Here bacteriology was pedicle and that drainage of the peritoneal 
brought before the Society for the first time as cavity was scarcely ever necessary, 
a science. On February, 20, 1889, a special meeting of 



Fig. 2. No, 20, Hanover Squ.are, London, England, as seen froni the garden. 

Sir James Paget was elected President in the Council was called to consider the oppor- 
1875. Among papers read in that year was tunity which was offered of securing new 
Bryant’s account of the diagnostic importance premises in Hanover Square. A General Meet- 
of the iliofemoral triangle. ing was held and it was decided to purchase 20, 

By 1879 ‘"i library which had contained Hanover Square for a sum of £23,000. A lease 
17,000 volumes in 1856 now contained 31,000. of the Berners Street house was assigned to 
Mr. (afterwards Sir John) Erichsen was Messrs. Phipps and Dawson, electrical engi- 
elected President and Lawson Tait recorded neers. The Society was offered the use of the 
the first successful case of drainage of the rooms of the Medical Society of London but 
gallbladder with removal of gallstones. they had no need to accept this offer as they 

In 1881 papers were read on “Listerism.” It immediately^ moved into Hanover Square, 
is interesting to try to find the differences The first meeting held there was on October 
between “Lister’s own Method” and so-called 22nd. The Society' arranged to accommodate 
modified “Listerism.” Sir Spencer Wells re- as tenants the Obstetrical, Microscopical, 
corded more cases of ovariotomy, making 1,000 Gynaecological, Clinical and Pathological So- 

American Journal of Surgery 




Whyte — Royal Society of Medicine 


17 


cleties, the Quickett Club and the Society for 
Relief Orphans of Medical Men. Business men 
must have been in charge of affairs for there 
were also private tenants in the basement and 
in the stables. 

On February 29, 1892, the Society’s first 
House Dinner was held. As time went on much 
thought was given to the popular amalgamation 
of th^ various medical societies in London and 
possibly with the formation of an Academy of 
Medicine. In i860 and 1861 and between 1868 
and 1870 there were proposals of union vith 
the various societies but each time the pro- 
posals had been dropped. 

In 1893 Sir Andrew Clark, then President, 
worked hard to bring about unity. He did not 
believe that any complete fusion or absorption 
of them was possible in one Society but he had 
ideas of federation. Sir Andrew died during his 
year of office and he was succeeded by Mr. 
Hutchinson. Again attendance at meetings fell 
off and in 1894 there was a dearth of papers. A 
Committee was appointed to report what 
should be done and changes were made in the 
bylaws. One new ruling, however, did more 
harm than good. It was decided that papers 
would be printed before being read and would 
be obtainable (in prooQ on application at the 
Society’s rooms. Later it was thought that this 
was too comfortable a rule and the lateness 
of the usual hour for dinner also militated 
against good attendances. 

In 1903 a beginning was made of the plans 
for a Centenary Festival. A Centenary Com- 
mittee was appointed in 1904. At the annual 
general meeting the President, Sir Richard 
Douglas Powell, commended to the Society a 
plan of union between medical societies in 
London. A conference was arranged and on 
April loth, at the Royal College of Physicians, 
a general meeting of the Societies was held. 
Sir William Church presided over the meeting. 
It was moved by Sir Frederick Treves, seconded 
by Sir Thomas Smith and agreed; 

“That in the Opinion of this Meeting, con- 
vened by the President of the Roj^a' College of 
Physicians, and composed of the Members and 
Fellows of the Royal Society of London, it Is 
highly desirable that an effort should be made 
to unite the principle Societies into a new body 
to be known as the Royal Society of Medicine.’’ 

Thus the Royal Medical and Chirurgical 
Society of London which had lasted for 100 
years looked forward not to extinction but to 

Januanr, 1950 


unity in the new Society of Medicine which had 
so often been envisioned. 

It was decided on legal advice to petition the 
King for a Supplementary Charter changing 
the name of the Royal Medical and Chirurgical 
Society of London to the Royal Society of 
Medicine. This was the desired fresh name and 
it provided for union with the other Societies. 

The Supplemental Charter was graciously 
granted to the Society by His majesty the 
King and this was dutifullj' accepted at a 
meeting held on Friday, June 14, 1907. Thus 
the idea first started in 1808, revived in i860 
and again about 1870 of a union between the 
Medical and Chirurgical Socletj" and other 
medical societies was realized. 

The Royal Society of Medicine has occupied 
a position of considerable eminence in the 
medical world from its inception. Not only has 
it carried on the great traditions of the Royal 
Medical and Chirurgical Society and the 
eighteen other societies which agreed to 
sacrifice their identity to the extent of be- 
coming autonomous sections of the new 
Society, but also has formed a tradition of Its 
own. As years have gone by there has never 
been a time when progress was not being made 
and medical history written. 

The Society was fortunate In having Mr. 
MacAlister as secretary librarian and Sir 
William Church, Physician to St. Bartholo- 
mew’s Hospital, as the first President. 

Medicine and surgery were represented by 
separate sections and from the beginning sub- 
jects of proctologic interest were discussed at 
the meetings of the Surgical Section. Of 
numerous papers many are worth noting. I 
would mention Ernest Hay Groves’ paper in 
January, 1909, entitled “The Functions of the 
Colon in Relation to Colic Exclusion” and In 
the same year the masterly description of “The 
Lymphatics oi the Colon” by Jameson and 
Dobson. At that time Harrison Cripps was 
Vice-President of the Surgical Section. In 191 1, 
the year before the present house of the Society 
was opened by His Late Majcstj' King George 
V at I, Wimpole Street, Wood Jones read his 
classical description of “The Delimitation of 
the Rectum and Its Sub-Divisions.” As time 
went on the great names in British Proctological 
Surgery were noted among the Proceedings of 
the Society. In 1911 we read the words of, 
among others, Swinford Edwards, Harrison 
Cripps, Frederick Eve, Herbert Waterhouse, 
Lockhart-Mummery and Gordon Watson on 



i8 


Whyte — Royal Society of Medicine 


“Tlie Operative Treatment of Cancer of the 
Rectum.” January i8, 1911, is the first time 
tliat Mr. Lockhart-Mummery is recorded in 
tlic Proceedings but from then on, especially 
after proctology became a nominated sub- 
section of the Society, there arc few volumes 
of the Proceedings without considerable and 
masterly contributions from the great man. 

A landmark in the history of British proc- 
tology was the formation of the subsection of 
proctology of the Royal Society of Medicine in 
1913 with Swinford Edwards as first President, 
Percy Furneval as Vice-President and Percy 
Lockhart-Mummerj' and W. Sampson Hand- 
ley as Secretaries. The first meeting was in 
November, 1913, and among the names of the 
Members of Council we note Charles Ryall and 
Ernest Miles. Ernest Miles by then was, of 
course, a great name. In the Lancet for Decem- 
ber 19, 1908, he had published his classical 
article on “A Method of Performing Abdomino- 
peritoneal Excision for Carcinoma of the 
Rectum and of the Terminal Portion of the 
Pelvic Colon.” He was Surgeon to the Cancer 
Hospital and we are happy to have his suc- 
cessor, temporal and spiritual, Lawrence Abel, 
At this meeting. Miles was also Surgeon to the 
Gordon Hospital for Diseases of the Rectum, 
represented here again by Lawrence Abel and 


his colleague, Ronald Raven. Miles and Lock- 
hart-Mummery dominated British proctology 
for years and manj'^ meetings of the subsection 
were enlivened b3' discussion, debate and 
repartee between them — one the advocate of 
the radical combined operation for cancer and 
the other the enthusiast who produced such 
wonderful results from his extended perineal 
operation. 

Such was the importance of the subsection of 
proctologj" that in 1940 it was elevated to the 
status of a full section of the Roj'al Societj^ of 
Medicine. The first meeting as a section was 
held on Maj' 8th when there was a discussion 
on “The Surgical Treatment of Idiopathic 
Ulcerative Colitis” opened bj" Lionel Norbur^" 
and W. B. Gabriel of St. Mark’s Hospital 
among others. The section has gone from 
strength to strength; some of jmii ma^' have 
attended our large and enthusiastic meetings 
when you came over to help us in other ways 
during the recent war j’ears. An evidence of our 
continuing enthusiasm is the presence of a few 
of the more important, I might saj’’ most 
important, office-bearers and members of our 
Society who are at the meeting enjoying j'our 
hospitality and instruction. I mean, of course, 
those of my English friends who have listened 
so patiently with the rest of you. 




Amencan Journal of Sursiery 



HISTORICAL HIGHLIGHTS OF THE AMERICAN 
PROCTOLOGIC SOCIETY 


Tom E. Smith, m.d. 
Dallas, Texas 


L ike many organizations the American 
Proctologic Society has some points 
■* of disputed history as to its founders and 
charter members. At various times the charter 
members have been listed as eleven, thirteen, 
fourteen and fifteen in number. Dr. Marion 
Pruitt, in his presidential address to the 
soeiety in 1937, listed eleven men as the 
founders.' 

Dr. George B. Evans,^ in remarks to the 
society concerning Dr. Joseph M. Mathews, 
said that there were thirteen members and that 
he was “number 13” and had always con- 
sidered it lucky. He remarked that he had been 
invited to attend the founding of the Society in 
1899 but had not been told that the preparation 
and presentation of a scientific proctologic 
paper was a prerequisite for charter member- 
ship. He stated that had it not been for the 
personal attention of Dr. Mathews and Dr. 
James P. Tuttle he would not have been elected 
to membership at the founding meeting. 

Fourteen charter members was the number 
given by Dr. Rollin H. Barnes in 1913 when he 
wrote in the following obituary, "Dr. Straus 
is the second of the fourteen charter members 
to die this year.”® 

On page 3 of the Thursday, June 8, 1899, 
edition of the “Ohio State Journal” published 
in Columbus, Ohio, a detailed write-up of the 
founding of the American Proctologic Society 
is given. This article stated that the member- 
ship would be limited to twenty-five and that 
there were fifteen members. A copy of this page 
is a prominent part of the historical exhibit of 
the Society prepared by Dr. Curtice Rosser and 
me with the assistance of Mr. Lewis Waters, 
director of the Medical Arts Department of 
the Southwestern Foundation Medical College 
of Dallas, Texas. 

While the article mentions fifteen members, 
only thirteen are listed and the topics of their 
papers follow: “The Importance of Giving 
Rectal Diseases Special Study,” Dr. Joseph 
M. Mathews, Louisville; “Pruritus Ani,” Dr. 
James P. Tuttle, New York City; “Surgical 

January'-, igso 


Treatment of Non-malignant Stricture of the 
Rectum,” Dr. Joseph B. Bacon, Chicago; “A 
Modification of Whitehead’s Operation for 
Hemorrhoids,” Dr. Samuel T. Earle, Jr., 
Baltimore; "The Proctoscope as a Factor in 
the Diagnosis and Treatment of Simple Ulcer- 
ation of the Rectum,” Dr. Leon Straus, St. 
Louis; “A Consideration of the Various Forms 
of Ulceration of the Rectum,” Dr. Lewis H. 
Adler, Jr., Philadelphia; “Rectal Carcinoma — 
Excision and Subsequent Colostomy,” Dr. B. 
Merrill Ricketts, Cincinnati; “The Limitations 
of the Kraske Operation,” Dr. Charles C. 
Allison, Omaha; “The Act of Defecation,” 
Dr. Thomas C. Martin, Cleveland; “Con- 
stipation Considered from the Standpoint of 
the Proctologist,” Dr. A. Bennett Cooke, 
Nashville; “Paper and Exhibition of New 
Instruments,” Dr. S. G. Gant, Kansas City; 
“Rectal Adenomata,” Dr. William M. Beach, 
Pittsburgh; “The Post-operative Treatment 
of Hemorrhoids,” Dr, J. R. Pennington, 
Chicago. 

This article fails to list the other two mem- 
bers, but the earliest published “Transactions” 
gives them as Dr. George J. Cook of Indian- 
apolis and Dr. George B. Evans of Dayton. ■* 
The first Transactions published in 1899 by 
Murdoch Brothers and Company of Allegheny, 
Pennsylvania, lists thirteen charter members on 
page I as follows: 

Dr. Jos. M. Mathews, Louisville 
Dr. Leon Straus, St. Louis 
Dr. B. Merrill Ricketts, Cincinnati 
Dr. Thos. Chas, Martin, Cleveland 
Dr. S. G. Gant, Kansas City 
Dr. J. Rawson Pennington, Chicago 
Dr. Jas. P. Tuttle, New York City 
Dr. Sam’ I T. Earle, Baltimore 
Dr. Lewis H. Adler, Jr., Philadelphia 
Dr. A. Bennett Cooke, Nashville 
Dr. George J. Cook, Indianapolis 
Dr. George B. Evans, Dayton, O. 

Dr. William M. Beach, Pittsburgh 
No mention is made in the minutes of the 
preliminary meeting held in the Great Southern 


19 



20 


Smith — Historical Highliglits of Society 


Hotel on June 6th and reported on page 2 of 
the 1899 “Transactions” about Dr. Chas. C 
Allison of Omaha, nor is his name mentioned 
in the minutes of the ofTicial first annual meet- 
ing reported on pages 3 and 4 of the first 
“Transactions.” It is impossible to explain 
why he should be listed in the Columbus news- 
paper as appearing on the program when he 
was not listed in the Transactions as either 
being present or presenting a paper and not 
being listed as a charter member. 

Interesting is the fact that Dr. Joseph B. 
Bacon of Chicago is not listed as a charter 
member yet his paper is reported to have been 
read by title at the June 7th afternoon meeting 
in the Chittenden Hotel. Furthermore, his 
scientific paper, “Scientific Treatment of Non- 
malignant Strictures of the Rectum,” was 
published on pages 20 to 27 of the first Trans- 
actions. We can only surmise as to why he did 
not become a charter member. 

Of further interest is the fact that pages i to 
4 of the first Transactions, which is the detailed 
report or minutes of the preliminary and actual 
first ofiicial meeting, relate that Drs. Evans of 
Dayton and Cook of Indianapolis entered into 
the discussion of the scientific- papers, yet 
neither presented a paper and both were 
elected charter members. Further still, while 
Dr. Evans did not present a paper at the first 
session, he had a paper titled “Stricture of the 
Rectum” published in the first Transactions 
on pages 74 to 82. 

One other inaccuracy appeared in the news- 
paper report. Dr. S. G. Gant’s paper was titled 
and published in the Transactions as “Chronic 
Diarrhea Due to Rectal Disease” and not 
“Paper and Exhibition of New Instruments” 
as related in the Columbus press. 

The press reported Dr. Mathews as having 
given a paper, “The Importance of Giving 
Rectal Disease Special Study.” The minutes 
state on page 3 of the first Transactions that 
“Dr. Mathews delivered an address commend- 
ing the organization and its objects. He then 
reported a case of prolapse of the rectum and 
exhibited a photograph of the same.” Yet 
in the published “Transactions” Dr. Mathews’ 
paper was •“ Diseases of the Sigmoid Flexure.” 

Before passing the press article it should be 
called to attention that the news reporter 
stated, “A new National Medical Association 
to be known as the American Proctologica/ 
"'as organized yesterday morning at 

1C uttenden Hotel.” This is, I am sure, the 


first of the thousand times of misspelling of the 
“Proctologic” portion of our Society name. 

The growth of the Society in numbers 
through the years has been orderly and has 
changed as the population and proctologists to 
serve it has increased. From thirteen members 
in 1899 it grew to thirtj^-four Fellows in 1909; 
thirt\'-seven Fellows and twelve Associate 
Fellows in 1919; fiftj'-one Fellows and twenty- 
nine Associate Fellows in 1929; seventy-four 
Fellows and ninety-two Associate Fellows in 
1939; and to eighty-seven Fellows and one 
hundred twentj^-seven Associate Fellows, one 
hundred forty Alfiliate Members and eighteen 
Senior Fellows in 1949. 

As time has passed Senior Fellowship and 
Affiliate Membership has been created to allow 
for a larger and more active membership on the 
part of proctologic specialists and those inter- 
ested in the field of proctology. 

It is of interest to note that no Fellows were 
elected in 1903, 1905, 1911, 1912, 1916, 1917, 
1918 and 1921. 

The society manifested an early interest in 
proctologic literature as Dr. Samuel T. Earle, 
Jr., began the “Progress of Proctologic Liter- 
ature” in the “Transactions” of 1904 and 
continued this until 1915.® There was no review 
from 1916 until 1924 when Dr. T. Chittenden 
Hill of Boston wrote on “Proctologic Advances 
Revealed in the Literature of 1924.”® The 
review was presented by Dr. Emmett H. 
Terrell of Richmond in 1925 and has been 
continued yearly with a different Fellow of the 
Society presenting this worth while feature of 
our annual meetings. The literature had 
become so voluminous by 1938 that it was 
divided into a malignancy and a benign section. 
Dr. William H. Daniel of Los Angeles presented 
the first malignant section review and Dr. 
George H. Thiele of Kansas City the first 
separate benign literature section. The review 
has continued in this fashion until 1947 when 
the “Transactions” were not published and the 
scientific papers were presented in the Ameri- 
can Journal of Surgery. In passing I believe we 
are deleting a most important phase of our 
program when we fail to have a review of the 
literature available for our members. It is true 
that it is a chore, but either we should continue 
to rotate this among the Fellows or we should 
procure this service from some accredited 
librarian for a reasonable fee. 

The recording of the annual meetings has 
been sketchy. A small volume of “Transac- 

American Journal of Surgery 



Smith — Historical Highlights of Society 


21 


tions” was published the first year but was not 
continued. In 1907 Dr. Rollin H. Barnes of 
St. Louis started a quarterly magazine called 
“The Proctologist” and it appeared regularlj'^ 
until his untimely death during the 1917 
meeting of the Society in New York City. 
During these years he was allowed to publish 
the “Transactions” but other Fellows were 
often named as editors." 

The proceedings of the 1917, 1919 and 1920 
meetings were published as one volume by the 
jMercury Publishing Company of New Bedford, 
Mass., with Drs. Ralph W. Jackson and John 
L. Jelks as the publication committee. There 
was no session in 1918 and the publication of 
the 1917 work had been postponed on account 
of World War i, this accounts for the one 
volume edition of 1920.® 

The “Transactions” continued uninter- 
rupted through 1942. There was no meeting in 
1943 so the next volume was that of 1944. 
Again there was no meeting in 1945 which 
brings us to the 1946 edition of the Transac- 
tions. The 1947 and 1948 papers have been 
published in the February and December, 1948, 
issues of the American Journal of Surgery. 
While this latter arrangement allows for a 
greater circulation of the excellent papers 
presented to our Society, we must admit that 
many of us are going to experience difficulty in 
keeping a consecutive file of the mimeographed 
minutes sent us following these meetings. I 
suggest we entertain the proposition of con- 
tinuing to issue our Transactions as a published 
work to keep our material in easier reference 
form. I emphasize that I see no reason at this 
time to stop our paper presentations in the 
American Journal of Surgery but that a small 
printed publication of our annual Transactions 
be started again. This will benefit us all and will 
make it a great deal easier on future members 
who have some historical theme they are 
attempting to develop. 

It is of note that the Society has encouraged 
the spreading out of proctologic influence as has 
been manifested by its interest in the creation 
of the Section of Gastro-enterology and Proc- 
tology of the American Medical Association in 
1917. The Society can point with pride to the 
fact that two of the Section’s first officers were 
proctologists as Dr. Dwight H. Murray of 
Syracuse was its first chairman and Dr. Louis J. 
Hirschman of Detroit its first secretary.®-*'’ 

At the 1937 Atlantic City meeting of the 
American Proctologic Society two of its 

January, ig^o 


Fellows, Dr. Marion C. Pruitt of Atlanta, who 
was its President, and Dr. Curtice Rosser of 
Dallas, had the Secretary and General Manager 
of the Southern Medical Association, Mr. C. P. 
Loranz of Birmingham, as honor guest. Mr. 
Loranz was impressed with the interest shown 
at this meeting and later, following conversa- 
tions and correspondence with Drs. Pruitt and 
Rosser, he extended approved authority for a 
trial organization meeting of the Section on 
Proctology of the Southern Medical Association 
at the New Orleans meeting in December, 1937. 
Two hundred eighty-seven doctors attended 
the meeting on December 2nd, and this was 
enough evidence for official establishment of 
the Section.” 

Before concluding this phase it will be of 
interest to many of the younger men here today 
to note and meet our British proctologist 
friends and to know that our Society on the 
occasion of its 25th anniversary had a joint 
meeting with the Subsection on Proctology 
of the Royal Society of Medicine in London 
in 1924. The highlights of that meeting were 
beautifully condensed by our Senior Fellow, 
Dr. Alfred J. Zobel of San Francisco.*® He 
said, “It was a splendid meeting, and we were 
most cordially received and royally entertained 
by our English colleagues. A Symposium on the 
injection treatment of hemorrhoids was a part 
of the program, and I always have felt that 
resulting therefrom came the deliverance of 
this valuable method of treatment from its 
taint of charlatanism. To the Fellows of our 
Society who were at the London meeting it was 
a revelation to see the swift and beautiful 
dissections of Mr. Miles and Mr. Mummery 
when they performed their respective ab- 
domino-perineal and perineal operations for 
cancer of the rectum. They were like a series of 
finely executed illustrations from out of a 
textbook.” So to our English conferes present 
today we say we hope historj’^ repeats itself 
with the above circumstances in reverse. 

In closing it seems proper to salute our past 
presidents and secretaries for without their 
labors there would have been no history to 
reeite today. 

Eleven of the founders were honored with 
the presidency, and since then there have been 
thirty-two other Fellows so chosen. Only three 
Fellows have been elected twice: Drs. Joseph 
M. Mathews, Louis A. Buie and Dudley Smith. 
Three other Fellows have served for two con- 
secutive years due to the contingencies of war: 



Smith — Historical Highlights of Society 


22 

Dr. Jerome Lynch during World War i and 
Drs. Homer I. Silvers and William H. Daniel 
during World War n. 

Only sixteen Fellows have been chosen 
secretary and it is to these men who have 
diligently attended to the great mass of detail 
associated with organizational work that the 
Society will ever be grateful. 

To the officers and workers of the past fifty 
years our Societj’’ says, “Congratulations on a 
job well done,” and to the ofircers and workers 
of the future the Society wishes you success 
and happiness. 


REFERENCES 

1. Transactions American Proctologic Society, page 

III, 1937- 

2. Ibid, page 8, 1928. 

3. The Proctologist, 7: 49, 1913. 

4. Transactions American Proctologic Society, page 8, 

1912. 

5. Ibid, page 5, 1936. 

6. Ibid, page 27, 1925. 

7. Ibid, page 3, 1936. 

8. Ibid, page 2, 1920. 

9. Ibid, page 3, 1936. ' 

10. Ibid, page 185, 1938. 

11. Smith, Tom E. Southern i\tedical Journal, 38: 

431-436, 1945. 

12. Transactions American Proctologic Society, page 

187, 1938. 




American Journal of Surgerxr 



THE PRESENT STATUS OF SOCIALIZED MEDICINE 

IN ENGLAND 


A. Lawrence Abel, m.s., f.r.c.s. 
London, England 


M ay I express how deeply I realize the 
honor of being asked to discuss the 
question of the present state of social- 
ized medicine in England and to assure you 
that I approach my task with due humility. 

I propose to glance briefly at the history of 
how a form of socialized medicine has come 
about, then to describe how it works and also 
the effects, both good and bad, it has had on 
various branches of our profession and the 
public; to draw lessons from the mistakes which 
we as a profession have made and, no less im- 
portant, the mistakes of the politicians. 

At the conclusion I will ask questions, many 
of which only you in the United States can 
answer. But where I think I can supply the 
answer, I will humbly offer my advice. 

HISTORY 

Fifty years ago at the turn of the century 
private practice flourished amongst the well- 
to-do but the large majority of the population 
was the industrial or working class for whom 
no aid was available for family doctor services. 
The main mass of these people had a very nar- 
row margin of Income with little thrift or 
savings and a serious illness or even a slight one 
was often a tragedy. 

Some doctors saw a patient and provided 
medicine for the equivalent of 25 cents a time. 
(We must remember money was worth at least 
double what it is today.) Sometimes the doctor 
looked after a community as a club and received 
only 50 cents a year from each household ; this 
charge included medicine. Again, in a com- 
munity of workmen such as miners a man 
might pay one penny a week, that Is a dollar a 
year, to cover all medical care for himself or in 
some instances for his family also. There were 
many different focal arrangements but most 
were bad with poor pay and long hours of 
drudgery for the doctor. 

Then came 1911 and the National Health 
Insurance Act. The effect of this was that in 
return for a few pence a week all industrial 
workers earning up to 81,250 a j'ear were in- 

January, 1950 


sured for medicines and family doctor services. 
The doctor received 81.50 a year for each 
patient on his panel or list. Although this made 
an improvement in the pay of the average doc- 
tor and in the care of the minor ailments of the 
working classes, it was not strictly “national” 
because it only covered approximately 10 mil- 
lion workers of the total population of about 40 
million. 

But it did provide a family doctor service 
either in the doctor’s office or the patient’s home 
for workers of low income limits. The benefits 
were increased early in the recent war to in- 
clude those with incomes up to 82,500 a year 
and all others engaged in war work. This meant 
that the family doctor service and medicine 
were available to some 20 million of the popula- 
tion of 48 million. During this time the doctor’s 
fees varied at the whim of the government and 
reached S2.50 a year for each person for whom 
he was responsible (or “at risk” as it is now 
called). 

It was misnamed a Health Service for it was 
only a sickness service and it was not a full in- 
surance as we understand it but only a family 
doctor service. Also, it did not provide help for 
any serious illness, e.g., pneumonia, appendi- 
citis, cancer. In fact an}'' illness requiring hos- 
pitalization was unprovided for under the 
scheme. 

During the first decade of this century hos- 
pitals were almost solely voluntary institutions, 
i.e., supported by the charitable subscriptions 
of rich and poor, although sometimes workers 
made regular contributions such as a penny a 
week to support their local hospital and thereby 
gain preferential admission when sick. Between 
the wars municipal hospitals increased and 
improved. A few attained a good degree of 
efficiency and medical care; but although the 
patient had paid for their upkeep out of his 
rates (local municipal taxes), every effort was 
made to make him pay again the full cost of his 
maintenance while in the hospital. 

Eor over thirty j'ears the medical profession 
has been asking for an improvement in the care 


23 



24 


Abel — Socialized Medicine in England 


of the sick and especially in the provision of 
better and more carefully planned hospital 
facilities. Various planning committees made 
reports and suggestions for improvements Ijut 
all fell on deaf cars of Socialists and Conserva- 
tives alike until the Coalition government 
heard them in the early part of the war. This 
government wanted a full time, state-salaried 
service, i.c., one doctor, one street; this was the 
most pernicious and degrading suggestion as 
you will readily appreciate. But workers in the 
form of the T.U.C. insisted on a patient having 
the right to the choice of his own doctor. 

A draft of the present act was published 
about 1945 and, in spite of many representa- 
tions to the contrary on points which would 
have made for better feeling between the politi- 
cians and doctors, was passed through Parlia- 
ment almost unaltered and came into effect 
Jufy 5, 1948. Its main provisions arc as follows: 
The Minister of Health is responsible for all 
provisions for the care of the sick. The service 
is available to 100 per cent of the inhabitants 
whether British, foreigners or temporary resi- 
dents, or even a visitor on holiday for a few 
days. 

You will be glad to learn that so far no new 
hospitals have been built to accommodate well- 
to-do Americans who want a sea voyage before 
having a free surgical operation, followed by a 
nice sea trip for the convalescent period on 
their return home. But we already have had 
foreigners arriving from other lands for free 
appliances, free spectacles, free radiotherapy 
and the like in order to save money at home. 
The cost of this service for the non-British in 
the first nine months has been approx imatelj' 
$ 1 , 000 , 000 . 

HOW IT WORKS 

Everyone may choose his family doctor and 
sign on to his “list.” If the patient is too ill to 
attend the doctor’s office, the doctor must go 
to his home. The doctor orders drugs on a 
special form and these are provided free on 
presentation of the form to a druggist. 

If dental treatment is needed, the patient 
may attend any dentist of his choice and any 
dental work is carried out free. If a consultant’s 
opinion is needed and the patient is too ill to 
attend the hospital, a consultant may be called 
and for this service will receive Si 7.00. Anj' 
patient who needs hospital treatment may go 
to a public ward at a hospital where no inquiry 
IS made as to his financial position and where 


all services arc free. It is estimated that every 
bed costs the state from S40.00 to S80.00 a 
week. 

(You should know that until shorti}' after 
the First World W’ar most of our hospitals had 
' no private beds or private wards. But in the 
last twenty-five years many of the voluntary 
hospitals had built private sections attached 
to or associated with the general hospital 
accommodation.) 

Any patient who wishes to have complete 
privacy of accommodation and to choose his 
own internist or surgeon must pa}' to the hos- 
pital authorities the full cost of the bed plus 25 
per cent (all of which goes to the coffers of the 
government), and, in addition, a fee to the 
physician, surgeon, anesthetist, pathologist, 
radiologist, etc., which in the aggregate must 
not exceed S300 for any one illness. In some 
hospitals not more than 15 per cent of the 
already depleted private beds are allowed to 
be available where the doctors may charge 
unlimited fees. 

Appliances may be ordered by the dentist, 
doctor or specialist and are provided “free,” 
e.g., dentures, spectacles, trusses, artificial 
limbs, wigs, wheelchairs and motor chairs for 
cripples. (Incidentally, much of the first few 
years of working was more than paid for by 
the money confiscated by the government. Not 
only has it seized real estate, buildings, etc., up 
to $8,000,000,000 but also much money which 
was owned by the hospitals.) 

Because of the demands for these so-called 
free benefits there is enormous delay, often 
running into many months, before they can be 
supplied. 

WHAT THE HEALTH SERVICE COSTS AND HOW 
IT IS PAID FOR 

The Health Service is part of a social security 
scheme. This is applicable to the whole com- 
munity and provides a large number of benefits. 
Among other benefits the social security plan 
includes the following: 

The Health Service. 

Maternity Benefit — Each mother receives $80.00 
at the birth of each child. 

Children’s Allowances — For every child after 
the first the household receives Si. 00 a week. 
Uriemployment Benefit — Each worker tempo- 
rarily unemployed receives about $7.00 a 
week. 

American Journal oj Surgery 



.Abel — Socialized Medicine in England 


25 


Sickness Benefit — Each worker unable to earn 
on account of illness receives about S6.00 to 
S7.00 a week. 

Widows’ Pensions — Anj^ worker’s widow re- 
ceives a few dollars a week. 

Retirement Pension — Female workers retire at 
sixty and male workers at sixty-five, and 
receive a regular weeklj^ pension as long as 
they live. 

Burial — A fee of S80.00 is paid to the mortician 
for burial. 

To begin to pay for all these benefits and 
services Si. 00 a week is levied from all wage 
earners. Out of this only 14 cents goes to the 
entire health service (hospitals, doctors, den- 
tists, chemists, opticians, nurses, administra- 
tion, porters, etc.). 

This weekly contribution of 14 cents pro- 
duces about Si20,ooo,ooo a year; municipal 
taxes produce a further $24,000,000. The total 
cost of the Health Service was originally esti- 
mated to be $600,000,000. 

The actual cost for the first six months has 
been $1,040,000,000. The estimated cost for 
twelve months is $1,400,000,000 but is likely to 
be much more. Even this scarcely includes any 
allowance for new buildings, hospitals, nurses 
homes, convalescent homes, etc., all of which 
are urgently needed. 

You will realize, therefore, that nine-tenths 
of the cost of the health service (not including 
any of the other social security services) must 
be provided from general state taxes and from 
this source not less than $1,250,000,000 are 
required annually. 

From the worker’s weekly contribution of 14 
cents only cents goes to the family doctor. 
But from general taxes the practitioner receives 
a further 6 cents a week making about $3.40 a 
year for each person on his list. 

One of the strangest features is that the 
average man-in-the-street is under the impres- 
sion that the whole of his weekly contribution 
of $1.00 goes into the pocket of the family 
doctor whereas in actual fact he gets only 
cents of it. 

You will readily appreciate that these health 
costs are exorbitant and far greater than the 
cost for health ser^dee in the old days of volun- 
tary hospitals and private enterprise. 

WHAT THE FAMILY DOCTOR MAY DO AND 
WHAT HE RECEIVES 

A family physician may have a maximum of 
4,000 persons on his list; his annual income 

January, ig$o 


would then be about $13,000. In many rural 
districts there are far fewer available persons. 
The average number of patients for which each 
doctor is “at risk” is 2,200 and the average in- 
come $7,000 a year, i.e., $3.40 per year per 
patient. An extra $30.00 is paid for every 
maternity case he attends. 

The state pays him a mileage fee for all 
automobile journeys beyond a two-mile radius 
which are necessary to attend a state patient in 
his own home. However, the mileage fee paid is 
less than the cost per mile to the doctor. 

He is still allowed to attend any patient not 
on his list who wishes to consult him privately 
and pay private fees. Similarly, any patient 
may consult any doctor or specialist in a private 
capacity and pay ordinary private fees except 
all full time specialists who are not allowed to 
have a private practice. 

HOW CONSULTANTS AND SPECIALISTS WORK 
AND WHAT THEY ARE PAID 

Before the introduction of the National 
Health Act there were two main classes of 
hospitals, voluntary and munieipal. 

The voluntary hospitals were almost entirely 
general hospitals and out numbered the munici- 
pal general hospitals. They were supported by 
voluntary contributions and payments made 
from patients who were financially assessed on 
admission and asked but never demanded to 
pay what they could reasonably afford toward 
their cost. Many had private accommodation 
available and patients in these beds paid their 
cost of maintenance. 

The consultants and specialist who worked 
in the voluntary hospitals did so without re- 
ceiving any payment whatever except fees 
charged to private patients in those hospitals 
where pay-beds were available. The specialists 
earned most of their living by attending patients 
in their offices and in private hospitals which 
we call nursing homes and in the private wards 
in voluntary hospitals which were seldom more 
tha 10 per cent of the total beds. Many volun- 
tary hospitals had no private accommodation 
whatever. 

Municipal hospitals were developed almost 
entirely between the two wars and were staffed 
largely by full time physicians, surgeons, etc., 
who, if they were specialists, received from 
about $4,000 to about S6,ooo a year. Other 
grades of interns and doctors received smaller 
amounts. 



26 


Abel — Socialized Medicine in England 


They included general hospitals and special 
hospitals for mental, tuberculosis and infectious 
diseases. As a rule no private (fee-paying) 
patients were treated in them. 

On July 5, 1948, the government seized ail 
hospitals together with all their equipment, 
land and finances to the estimated value of 
88,000,000,000. They tell me that King Henry 
VIII (who you will remember confiscated the 
monasteries in the sixteenth century) was heard 
to turn in his grave that day! 

The hospitals thus compulsorily acquired 
numbered about 3,000. Only 10 per cent of 
religious and similar institutions were exempted. 
Since that time no means test and no financial 
inquirj^ has been made concerning any patient 
admitted. 

Terms and conditions of ser%'icc for specialists 
had not been and have not yet been worked out 
and agreed but the proposal for payments 
which will be backdated to July 5, 1948, arc as 
follows: 

A specialist if working full time is estimated 
to be able to work eleven half-days per week. 
Each half-day is reckoned as three and one-half 
hours including travel to and from the hospital. 
Most specialists, however, wish to be employed 
in the service for only part of their time, the 
remainder being spent in private practice. For 
the first time the former voluntary hospital 
specialist receives payment for his services at 
the rate of approximately S640 per half day 
per year at age thirty-two, rising to a maximum 
of approximateb^ Si, 000 per half day per year 
at age forty but no higher (i.e., approximately 
S 1 2 at age thirtj^ rising to S20 at age forty and 
over per half-day). At first sight this appears 
quite generous for those who have done the 
work for nothing before but we will see later 
that with few exceptions private practice has 
decreased or even largely disappeared and for 
many the government fee has become the sole 
or almost the sole source of income. 

The maximum time a specialist who still 
wishes to do private practice may work in the 
hospital service is nine and a half half-days per 
week. But in addition he may be called to con- 
sult with a family doctor to the home of a 
patient who is too ill to be brought to hospital. 
For this he is paid $17.00 per case with a maxi- 
m^um of 200 such consultations in any one year, 
he is called to see more than the permitted 
he has to do so without fee. 

^e ull time specialists who were attached 


to the municipal hospitals were given a guaran- 
tee of being continued in the new service. The 
part time specialists, who constitute the major- 
itjh have no such guarantee and no security 
of tenure of their posts or the number of half- 
daj's thej' may work. 

You will observe that the income earned b^' 
the average full time municipal specialist will 
be nearly doubled although his work on the 
whole has not been of the same standard as the 
work of the voluntary' hospital, including uni- 
versity teaching-hospital specialists. The latter, 
owing to the great reduction of private prac- 
tice, is suffering from a lowering of income and, 
in many cases, acute hardship. 

In addition to the aforementioned fees all 
specialists may apply for an additional annual 
paj'inent for exceptional ability or merit but 
this is only available for 34 per cent of all 
specialists and is the proportion of the number 
of his half-days to eleven, of an average sum of 
$4,000. For example, a consultant working half 
his time (five and a half times three and one- 
half hours a week) might get $2,000 per annum 
extra if he can convince a committee that he is 
superior to his colleagues. This is an invidious 
task for the committee and the applicant and is 
likely to cause much heart-burning and 
acrimony. 

THE EFFECTS OF THE SERVICE SO FAR 

Effect on the Public. There can be no 
doubt that a big proportion of the public loves 
It. The thoughtlessness and imprudent greed 
which characterizes the man or woman who is 
stupid enough to believe that because they are 
paying nothing at the time they are getting 
something “free,” especially if it is “out of the 
government,” has to be seen to be believed. 

Almost all wage earners and a big proportion 
of the more well-to-do have scrambled for the 
benefits of the service. The demand for teeth, 
hearing aids, brassieres, wigs and spectacles 
has exceeded the expectations even of those 
who thought they understood human nature. 

It is already obvious that the better classes 
are taking advantage of the free outpatient 
clinics and this is true of free inpatient accom- 
modation also. 

The most serious aspect from the public’s 
angle is that the apparent material benefits 
which the^^ get at exorbitant cost cloak the real 
loss of true medicine. The public must realize 
that true medicine means early diagnosis and 

American Journal of Surgery 



Abel — Socialized Medicine in England 


27 


early and good treatment. What they had under 
the old system was good and increasingly better 
doctoring. I sincerely warn the people not to be 
fogged by a few so-called “ free” material things 
to the exclusion of that intangible thing — good 
medical care. 

Effect on the Nation. It is ver^"^ doubtful 
whether any country can afford to make avail- 
able an essential service without the barrier of 
some fee at the time. Experience has shown that 
the public has neither the prudence nor the 
control not to jump at something called “free.” 
Something you do not pay for, you do not value 
or bother much about. 

Therefore, to control the irresponsibility of 
the masses you must have either a small “sanc- 
tion ” at the time or run the service as a “grand- 
in-aid.” 

To the politicians and planners I would say: 
When your expert actuaries have calculated the 
cost, double it, for that is the experience in 
Great Britain. But as the first nine months does 
not include new and urgently needed extra 
accommodations for patients, nurses and doc- 
tors, I would say be very wise and treble the 
estimates. This has been the experience of New 
Zealand which has had a state medical service 
for some years. 

Effect on the Family Doctor. Among the 
main changes that have happened are the 
following: (i) The tendency is for the family 
doctor to have to see more patients. It is not 
uncommon for a doctor to see 60 or even 100 in 
an evening session in his office. This means that 
the doctor is a sorting station for sending 
patients to the hospital; (2) There is a marked 
increase of non-clinical work. Many forms have 
to be filled In, multiple certificates have to be 
issued and much more clerical work has to be 
undertaken. It is estimated that the main cause 
of many doctors being overworked today is 
the increase of some 25 per cent in non-medical 
work. This constitutes a main danger and 
clinical excellence will suffer because of the 
growing importance of non-clinical work. (3) 
An increase in multiple consultations. The doc- 
tor goes to see Mrs. Brown who is sick. When 
he has dealt with her she says, “Now that 
you’re here, doctor, just look at Willie and 
Anne and Jim and baby.” This is a good thing 
because it not only removes the financial barrier 
to seeking early aid but also brings the doctor 
into more intimate touch with the normal and 
near-normal. But it is a bad thing if his day’s 
work is disorganized and those who are really 

January'^, ig^o 


iir cannot be attended which, in fact, is now 
sometimes happening. (4) It is now much more 
difficult for a young doctor to get into practice 
than before. 

As you probably know, in the old days before 
July 5th a doctor would become an assistant or 
would buy the good will of a practice. For this 
he often had to borrow money. This was re- 
garded by many as a good method because, 
having sunk capital into the practice, it gave 
the man the continued incentive to do good 
work. The Socialist politician however called it 
the “buying and selling” of human lives but 
that is just nonsense. What happens today! 
The doctor has to fill in several forms, apply to 
one of the many executive councils and take 
his place in the queue without having anj' 
personal contact with the practitioner who 
needs a partner or successor. He may be re- 
quired to attend before a committee and possi- 
bly be offered a type of practice which is not 
congenial and which is in a locality unsuitable 
for him or his family. 

Under present conditions the position is made 
worse by the lack of accommodation and 
executive councils are actually advertising in 
the medical journals in these terms: 

“There is a vacancy for a family doctor 
at . . . There is no accommodation avail- 
able. Applicants must first secure accommoda- 
tion in the area before making application 
for the vacancy and applications must be 
made within 14 days of the appearance of this 
advertisement.” 

The preposterous situation thus created is 
that a number of candidates are required to 
arrange accommodation, both professional and 
domestic, and commit themselves to a liability 
before applying for a post to which only one of 
them can be appointed. 

This means that each new entrant is sub- 
jected to what is in effect direction of labor. 
Economic necessit3’^ will compel him to go 
where he is sent. Even sons and daughters of 
practitioners who qualified, believing they 
would become their father’s partners or suc- 
cessors, are being rejected by the committee on 
grounds of redundancj^ or because other appli- 
cants to practice in the area have a prior claim. 

This adds up to the fact that in the old days 
it was easier to get into practice bj"^ borrowing 
monej’^ than going through the present difficulty 
of wending jmur waj^ through the bureaucratic 
machinerj" that surrounds the service todaj'. 

I would also call your attention to this anom- 



28 


Abel — Socialized Medicine in England 


aly. A doctor who had a small, good class prac- 
tice has now a small, poorly paid practice 
(e.g., if a doctor was in a good middle or better 
class district with only, say, 800 inhabitants, he 
made an income in the neighborhood orSio,ooo 
to Si 2,000 a year). If he enters the scheme and 
all those people take advantage of the service, 
his income drops to about 83,500 a year. Some 
men have had to leave a congenial area of this 
kind and go to a more industrial and more 
populated area or emigrate. 

The doctor practicing in a big industrial dis- 
trict gets an even bigger practice, is well paid, 
but has much form-filling to do and is unable to 
give his patients the best possible attention. 

I also question if the men attracted to medi- 
cine under a state ser\’icc will be of the same 
caliber as before. 

It may interest you to know, however, that 
95 per cent of the British public have registered 
with a family doctor and 95 per cent of general 
practitioners are serving. 

THE EFFECT ON THE QUALITY OF MEDICAL 
CAHE 

It is believed that the quality of medical care 
is likely to suffer with the growing proportion 
of non-clinical work and with the sense of 
frustration which is afflicting some men. 

You may ask, can a doctor really look after 
4,000 persons properly? But remember the 
average is only 2,200 and they are not all sick 
all the time but only persons for whom the doc- 
tor is “at risk.” 

If you lower the maximum to the level of the 
average, you are heading for a full time, state- 
salaried service; therefore, the permitted maxi- 
mum must be high if the really industrious doc- 
tor is not to be completely eliminated. Once 
the maximum nears the average, all practi- 
tioners will be reduced to a common level and 
skill, personality, devotion to work, attentive- 
ness to patients, and reputation will count for 
little or nothing. 

When a doctor has the maximum number on 
his list he can only increase his income by 
private, fee-paying patients not on his list. He 
can give them a more agreeable service (e.g., at 
their time or at their home and not in the queue 
at his office); in other words give a more per- 
sonal attention with more frills. It is not an 
thing to find a doctor’s waiting room 

u and sick people lined up in the street outside. 


HOW THE INTRODUCTION OF THE SERVICE HAS 
AFFECTED THE HOSPITAL 

The repeated suggestions of the profession 
that hospitals should be grouped has been 
adopted. This Is a good point because it means 
an economy of manpower and an upgrading of 
the type of work and experience the specialist 
has. For example, there is no room in a small 
town for a full time dermatologist. One man 
who might be a family doctor part of his time 
would spend part of his time combining a little 
work in dermatology, in car, nose and throat, 
and in oj^hthalmology. With the grouping or 
regionalization of hospitals, with several towns 
and villages in the group, there is room for a 
full time dermatologist, a full time ear, nose 
and throat specialist, a full time ophthalmolo- 
gist and so on. 

Regionalization or grouping of hospitals is 
therefore economy of manpower, means better 
experience for the specialist who therefore gives 
the patients the benefit of a better opinion and 
insures better care for the patients. 

Another good point is that the state has 
assumed financial responsibilitj" for seeing that 
hospital beds are where they are needed and 
that they are properly equipped. 

But those of you who have had experience of 
bureaucratic promises, whether verbal or 
written, know what a difference exists between 
the promises and what actually conies aboilt. 
Today it is more difficult for a patient to get 
into the hospital. In some areas there are wait- 
ing lists of from twelve to eighteen months be- 
fore patients can be admitted. Although I say 
it is good for the state to assume financial re- 
sponsibility, this is only true if the promises are 
fulfilled. 

On the other hand, for the state to have 
become the owners of all hospitals is both un- 
necessary and wicked. There should be no 
state monopolj' of hospital beds. Healthy com- 
petition is good for any business! 

At the ivhim of the state private beds have 
become public beds; the price of private beds 
has gone up and in manj^ cases the charge to the 
patient has been doubled. Not only is the pri- 
vate patient charged the full cost of the bed 
but also he has to pay in addition 25 per cent 
over and above that cost; whereas if he were in 
the adjoining general ward, he would be charged 
nothing. The effect of this has been that in 
many districts private practice for the specialist 
has almost disappeared. » 

American Journal of Surgery 


Abel — Socialized Medicine in England 


29 


HOW HOSPITAL FINANCES ARE AFFECTED 

A bad point is that hospital finance now de- 
pends on public finance and already the econ- 
omy screw is being turned. For example; Re- 
cently the Ministry of Health ordered a 10 per 
cent cut in hospital expenditure. What does 
this mean? Hospital expenditure consists, in 
regard to 63 per cent of its total, of salaries and 
wages which are covered by national wage 
scales. These cannot be cut; in fact, they tend 
to increase on account of the agreements and 
regular increments of salary and because under 
a bureaucratic system more and more officers 
are appointed to administer the service. There- 
fore, a 10 per cent cut of total expenditure 
means a 30 per cent cut of running costs which 
are able to be manipulated. 

In one hospital group porters have had to be 
discharged and the money spent on patients’ 
food reduced by $20,000 a year. In the old days 
a cry to the public was sufficient; we relied on 
charity and it always got us there in the end. 
Today it is no good crying to the treasury. 

I have already told you that the patient 
enters the hospital with no financial inquiry. 
He therefore seeks to enter more readily and 
leaves more reluctantly. This means the dimi- 
nution of the utilization of beds and, as I have 
said, some waiting lists for hospitals are reach- 
ing enormous and alarming limits. Recently all 
hospitals were instructed to make available 10 
per cent of their beds for the chronically sick. 
This means that 10 per cent of an active, well 
organized, well equipped hospital is redundant. 
This type of patient depresses the other 
patients, does not need the expensive equip- 
ment and attention of the specialists and, in- 
stead of wasting a hospital bed costing S60.00 
a week, could equally well be accommodated in 
a less well equipped and well staffed institution 
at a cost of, say, S15.00 to S16.00 a week. 

It is like making the public purse pay for 
paupers being accommodated in the Waldorf- 
Astoria. 

HOW THE SERVICE AFFECTS THE SPECIALIST 

On the whole the specialist has gone on with 
his work in spite of a sense of grievance and 
frustration. He is now paid for his hospital work 
and the younger men, interns and training 
specialists, are better paid than before. Many 
people think this is a good point as it does away 
with the years of financial hardship which many 
of us went through in our early days. 

Januanr, ig^o 


It has meant, however, that the specialist is 
now' the paid servant of the hospital and not the 
voluntary partner and, as w'e all know', a paid 
servant is soon made to feel it. Small details act 
as pin-pricks, e.g., permission to be absent. Is 
it going to be permission w'ithout pay or per- 
mission with pay or will the time absent be 
deducted from the annual leave period and so 
on? Bureaucracy always gets you on details. 

No one know'S yet w'hether he w'ill be classi- 
fied as a specialist or as a low'er grade doctor. I 
should explain that in many mental and tuber- 
culosis institutions there are at the bottom 
junior interns undertaking their first six or 
tw'elve months’ residency, and at the top 
recognized specialists with higher degrees and 
qualifications. In between these there is a group 
of men varying in age from thirty-five to sixty 
w'ho are long past their internship but still 
could not be classified as specialists. To these 
the title of Senior Hospital Medical Officer was 
given. 

It was hoped that this grade w'ould die out. 
Unfortunately, this grade has been seized upon 
by the politicians as a great money-saving loop- 
hole. Many men that 3'ou or I w'ould have 
classified as specialists are being down-graded 
into this classification. For example: In a small 
tow'n w'here there is insufficient surgery to sup- 
port a full time surgeon, good average surgery 
has been carried out by men also engaged in 
work as family doctors. The same is true in 
England in small tow'ns regarding anesthesia. 
An enormous proportion of these men are being 
graded not as specialists but as Senior Hospital 
Medical Officers and although they are doing 
specialists’ w'ork, they are paid much less than 
the scales laid down for those who are desig- 
nated “specialists.” 

Even in some big centers w'here six or eight 
men devote their whole time to, sa^', anesthesia 
and are attached to the staff of a hospital, onij' 
one or tw'o are being graded as specialists and 
the rest as Senior Hospital Medical Officers. 
This again is a cause for great dissatisfaction up 
and down the country'. 

Another pernicious thing is as follows: When 
hospitals w'ere grouped together, it w'as prom- 
ised that all present day specialists w'ould be 
given work within the group corresponding to 
the w'ork thej' previously' did. What do w'e find? 
In several instances the main hospital of the 
group is taking over the beds of the smaller 
associated hospital w'ithout providing any work 



30 


Abel — Socialized Medicine in England 


for the displaced specialists. Some of these men 
have no other hospital appointment and are 
literally being “thrown into the gutter” in 
spite of the authorities’ previous promise to the 
contrary. 

The specialists’ private practices could be 
encouraged in hospitals instead of discouraged. 
If this was carefully and reasonably clone, it 
would improve the good will of the specialists 
and might even mean that the big salary bill to 
specialists could be reduced. 

We do not j'Ct have any ideas as to what, if 
any, medical researcli will be allowed nor do we 
know what scales of salaries for teachers in 
medical education are proposed. 

GENERAL EFFECT UPON ALL nUANCHES OF 
THE PROFESSION 

Even now after more than nine months of 
working there is no fixed rule with regard to the 
salary payable to either the family doctor or 
specialist. The government still has not prom- 
ised us the right of arbitration which we believe 
should be a condition of entry. 

Many of the best doctors have to spend their 
time in high political scheming and not in real 
medicine. As things have turned out, many of 
the tilings we fought for have really not been of 
great importance. The greatest danger of all 
may be the very existence of a bureaucratic 
machine which, by the turning of the screw, 
can do more damage to the doctors and hence 
more damage to the general welfare of the 
patients than anything else. With the bureau- 
cratic machine there is the perennial danger of 
interference by the turning of the screw not only 
on finance but also, although not obvious at 
present, on clinical matters and on the little 
details of such an enormous and impersonal 
service. 

Another reflection 1 would make is that prob- 
ably our biggest mistake was not to fight to the 
death the i oo per cent issue. I want to ask you 
and want you to ask yourselves: Have you a 
portion of your population who cannot afford 
adequate proper medical attention? This must 
be faced. If you have, then surely a solution 
must be found. But I warn you and implore you 
to take care that those who can afford to pay for 
it themselves are not provided for! 

Among the reasons for this solemn warning 
>s this. A man’s independence is in proportion 
to the number of sources of his income. A doc- 

r more than anyone else is and must be an 


individualist because his work is personal and 
individual to each patient. Therefore, he must 
keep his freedom, his independence, his indi- 
viduality. If only the state pays him, his free- 
dom is lost. Immediately all doctors are “in the 
bag” and at a erj- from the trcasur 3 ' for eco- 
nomic cuts Iiis income will be cut. This has hap- 
pened before under the National Health In- 
surance Act. If a service is limited to the low 
income group j'ou will not suffer. In fact, you 
maj' gain b.y it for the younger men are likely 
to receive a living wage at a higher level than 
under present conditions. Therefore, I ask j'ou 
again: Can you give full service under private 
enterprise at a price the patient can afford? If 
not, there must be some form of state aid or 
state partnership or insurance, either voluntarj' 
or compulsory, with some form of state control. 
But again 1 say, take care that those who can 
afford it arc not provided for! 

Another general reflection is t!iat it is alreadj' 
obvious during the first year of service that the 
government, as it begins to think it has got you, 
gets dustier and dustier in its attitude towards 
3'ou. As .you are in an independent profession, 
the government listens to you although seldom 
takes advice. As the public loves the service, no 
part}' that might come into power in Parliament 
will dare recommend its termination. No party 
would alter it very substantially. The great 
tragedy of the whole thing is that the doctors 
have been brought into the service by a form of 
blackmail, i.e., economic pressure. Many are in ■ 
the service with ill will whereas with tact, care- 
ful negotiation and reasonable compromise, 
their help could have been obtained with good 
will because the main principle of the profession 
was that we were out to help the government 
establish the best possible health service for the 
nation. 

SUMMARY 

To sum up, the service is a mixture of good 
and bad. The good is naturally less obvious 
because all concentrate on the defects but the 
bad too is not obvious. In the main the dangers 
seen now for the most part derive from the 
very existence of bureaucratic medicine and all 
that a bureaucratic machine can do. If there is 
the problem of sick people who cannot afford 
to pay for the best possible modern medical 
treatment, you must recognize the necessity for 
some form of insurance serxdce. But let it be an 
insurance which the wage earner pays and 
knows he is paying or an insurance for a “grant- 

American Journal of Surgery 



Abel — Socialized Medicine in England 


31 


in-aid,” so that the people do not get the idea 
that someone else is paying for it but know that 
they are paying themselves. 

I question if voluntary insurance is enough. 
Would the imprudent join such a scheme? 
Whatever you do, limit the state insurance to 
those who need it leaving those who can afford 
to provide for themselves to do so. Do not for- 
get that it appears the principle of our present 
government is that they do not trust anyone 
to spend his own money and therefore collect it 
and spend it for him. 

In spite of what I have said about the present 
health service being here to stay, do not forget 
that the British have the reputation of losing 
all battles except the last. We have partly lost 
the first battle; however, governments come 
and governments go but the spirit of medicine 
in the service of humanity goes on forever. So 
the last battle is not yet fought between our 
profession and bureaucrac3\ 

America also has a reputation ! After we have 
suffered for months or years America takes an 
interest, begins to understand, develops new 
lines of thought, learns from our mistakes and 
also comes to our aid before it is too late. This 


time it will not be with planes, guns, men and 
food, but perhaps with the moral example of a 
really sound health service for the nation based 
on freedom for the patient and the doctor and 
not upon the slavery of the bureaucrat. 

A service should come by evolution and not 
revolution. The patient should liave the right 
to contract out of the service. With a service 
covering 90 or 95 per cent of the population you 
are safe and free; but when the contract covers 
100 per cent, you are slaves. 

One of Abraham Lincoln’s most famous 
speeches began with the words: “A house 
divided against itself cannot stand.” I believe 
that he would have continued: “This profession 
cannot endure half slave and half free.” 

I think if Abraham Lincoln had been here 
today he might have used words something like 
these: 

It is for us to be here dedicated to the great 
task before us — that we here highly resolve 
that this profession under God shall have a new 
birth of freedom and that freedom of medical 
care and treatment of the people, by the people, 
for the people, shall not perish from the earth. 


Januaiy, ig^o 



papers of the Icteftttfh Sessions 


THE ANAL DUCTS AND THEIR CLINICAL SIGNIFICANCE 

Guy L. Kratzer, m.d. 

Allentown, Pennsi'^lvmiia 


T he management of Infections of the 
terminal bowel and adjacent structures 
constitutes a large and important part of 
proctologie practice. The majority of cases are 
managed successfully because the problems 
they pose are classic. Usually the infection 
Table i 

OBSERVATIONS ON TWENTi' CONSECUTIVE CASES OF 
ABSCESS IN WHICH primary OPENING COULD NOT 


BE DEMONSTRATED 



Years 

Cases 

Per 

cent 



14 

70 

Female 


6 

30 

Average age 

39-7 


Primary without draining sinus. 


8 

40 

Recurrent with draining sinus. . . 


12 

60 

Average duration 

4-9 



Situation in relation to anorectal 




canal 




Anterior 


8 

40 



12 

60 

Previous surgeiy 

.... 

12 

60 

Without previous surgerv 


8 

40 

Type 




Perineal 


8 

40 



5 

25 

Retrorectal 




Postanal 



25 



I 


None of the cases showed recur- 




rence following drainage and 




removal of indicated crypts 




Followed 3 years 


8 

40 

Followed 2 years 


4 

20 

Followed I year 


8 

40 


becomes localized and a diagnosis of abscess is 
made. This localization may occur below or 
above the levator ani muscles. If it occurs 
below the levator muscles, the abscess should 
be classified further as ischio-anal, perineal or 
If it occurs above the levator, it 
s ou d be identified as either retrorectal or 


pelvirectal. These abscesses may occur as a 
combination of two or more of these tj'pes. 
Proper surgical drainage is instituted and at 
the same time or subsequently' the primary 
opening is found and eradicated. 

The present study' concerns a group of 
twenty' patients with pararectal abscess (Table 
i), none of whom appears to be one of the 
classic types. This group represents patients 
who had a pararectal abscess with or without 
draining sinuses. They' are similar to the 
classic group in that the abscesses occur in the 
usual locations. They' are dissimilar in that an 
obvious primary' or internal opening was not 
demonstrated. An objective clinical study' of 
this group of patients was made. It is not 
claimed that anything new has been added to 
our present knowledge of abscess or fistula. It 
is also acknowledged that these patients could 
have had abscesses and sinuses not caused by' 
primary' infection in the anal cry'pts. However, 
it is significant that this series is made up of 
consecutive patients who had abscesses in 
locations where, following drainage, one would 
e.xpect a resultant fistula. The abscess in each 
of these patients was treated successfully by' 
Incision and drainage in the usual fashion plus 
e.\cision of the anal cry'pts in the portion of the 
anal canal where one would naturally' expect to 
find the primary' opening of a classic fistula. 

Special care was exercised in each instance 
not to make a false passage with the probe. 
Muscle fibers were not severed. The procedure 
consisted of uncapping the abscess cavity' plac- 
ing the incision lateral, anterior or posterior to 
the sphincter muscle, depending upon the loca- 
tion of the abscess, and excision of the cry'pts 
and interv'ening skin of the corresponding por- 
tion of the anal canal. (Fig. i .) 

This group of patients became more inter- 
esting when it was realized that cure did not 
necessitate severance of any portion of the 

American Journal of Surgen' 


32 


Kratzer — Anal Ducts 


33 


sphincter muscle. Possibly this presentation 
will stimulate the interest of other observers 
and conceivably a way to cure all fistulas in this 
manner may be found. The study indicates 
that certain abscesses do form without visible 
communication with the anal crypts and that 
such abscesses are treated successfully by in- 
cision and drainage along with excision of the 
corresponding crypts. Whether these abscesses 
and draining sinuses would have been eradi- 
cated by incision and drainage alone, without 
excision of the corresponding anal crypts, is a 
question needing further investigation. How- 
ever, it is significant that several of these pa- 
tients had an abscess followed by spontaneous 
drainage recurring over a period of many years. 
This information suggests that incision and 
drainage alone would not have resulted in cure. 

Buie* described perianal lymphatic abscess 
found particularly in the perineal area and 
occasionally in other parts of the perianal area. 
These abscesses and sinuses, similar to the 
lesions cited in the present study, have no 
visible communication with the anorectal line 
and their origin was attributed to infection 
carried from the crypts along the lymphatics. 
The present study neither proves nor disproves 
this suggestion. However, an additional avenue 
of infection will be described. 

The usual sites in which pararectal abscesses 
develop have been mentioned. Knowledge of 
the anatomic boundaries of these sites is help- 
ful in their treatment and aids in understand- 
ing the spread of anorectal infection. The post- 
anal space or posterior levator space as de- 
scribed by Courtney^ lies posterior and lateral 
to the rectum. Its internal boundary is the 
combined longitudinal muscle layer of the 
rectum in the male and the rectovaginal septum 
in the female. Above and behind lies the recto- 
coccygeus muscle and to the side lies the 
superior layer of the levator. Below is the 
anococcygeal muscle; to the side is the superior 
layer of the levator ani muscle. Perineal ab- 
scesses occur, usually subcutaneously, anterior 
to the transverse perinei muscles. The ischio- 
anal fossa is bounded laterally by the obturator 
fascia, obturator internus muscle and ischial 
tuberosity; medially by the internal and ex- 
ternal sphincter muscles; above bj" the levator 
ani muscle; posteriorly by the gluteus maxi- 
mum muscle and sacrotuberus ligament and, 
anteriorly by the transverse perinei superficialis 
muscle and perineal fascia. The pelvirectal 
space is bounded above by peritoneum, below 

January, ig^o 


by the levator, behind by the lateral ligaments 
and rectum and in front by the bladder, pros- 
tate and seminal vesicles in the male and the 
uterus and corresponding broad ligament in the 
female. The retrorectal space is situated in 
front of the sacrum, behind the rectum, below 

A 

/ \ 

/ \ 



Fig. I. This diagram indicates method of e.vcision 
of crypts and overlying skin. 


the peritoneum and above the levator muscle. 
The description of the foregoing anatomic 
boundaries was taken from Bacon. ^ 

For many years proctologists have been 
interested in the method of spread of infection 
from the crypts to the pararectal spaces. It is 
significant that in the patients comprising this 
series adequate drainage of the abscess and 
removal of crypts in the corresponding portion 
of the anal canal apparently prevented further 
abscess formation. This suggests that the 
portal of entry was the crypts and lymphatic 
drainage alone could not explain the mechanism. 

In 1 880 Hermann and Defosses* described 
simple and branched ducts lined with epi- 
thelium which emptied into the anal crypts. 
This work was confirmed by Johnson,® Lock- 



34 


Kratzer — Anal Ducts 




Fig. 2. Normal crypt. X 6o. 

Fig. 3. Subacute cryptitis. X 80. 

Fig. 4. Normal duct. X 75. (Courtesy of Surg., Cynec., & Obst., 84: 333-338, 

1947.) 

Fig. 5. Subacute periductal inflammation. X 100. (Courtesy of Surg. Cynec. 

& Obst., 84: 333-338, 1947-) 

hart-Mummery/ Harris,’’ Tucker and Heilwig,* 
and Pope,® to name a few. Lockhart-Mummery 
suggested that these ducts might be vestigial 
remnants of the sexual scent glands of lower 
animals. In 1936 Bremer’® noted the postnatal 
disappearance of secretory cells from the anal 
ducts in human beings. In the same year 
Morgan” observed that most of the ducts had 
their orifices in the posterior portion of the 
anal canal. 

In 1947 Dockerty and P® reported a study 
® t e histopathology of the anal ducts with a 

American Journal of Surgery 


view to verifying or disproving certain state- 
ments relating to their incidence, position and 
significance. The anal canals of a number of 
human embryos and of one male stillborn infant 
were secured for study of the developmental 
aspects of the ducts. Similar material was 
secured from ten monkeys. For the study of 
possible inflammation in the anal ducts of 
human adults one hundred surgical specimens 
were selected from patients in whom removal 
of the rectum and anus had been performed 
for lesions of the rectosigmoid. Finally the 


Kratzer — Ana! Ducts 


35 



Fig. 6. Acute inflammation in lumen of duct. X 140. (Courtesy of Surg., 
Cynec. & Obst., 84: 333-338, 1947.) 

Fig. 7. Duct in human embryo. X 100. 

Fig. 8. Duct originating in crypt. X 75. 

Fig. 9. Duct leaving crypt and traversing submocosa. X 75. (Courtesy of 
Surg., Gynec. & Obst., 84: 333-338, 1947.) 


slides made during a previous study of one 
liundred cases of cryptitis were reviewed to 
check on the presence of associated anal ducts 
and their possible role in the spread of infec- 
tion. Merely a summary of these observations 
will be given. The study amply confirmed 
previous observations that epithelium-lined 
ducts are to be found in monkeys, human 
embryos and human adults. They may be 
demonstrated in about 50 per cent of human 
anal canals. From openings in the anal crypts 
(most often posterior) the ducts course outward 
and downward, often penetrating the external 

January, ig§o 


sphincter. The majority are lined with transi- 
tional epithelium but definite mucus-producing 
cells may be demonstrated in 10 per cent of the 
specimens showing ducts. About 24 per cent of 
these ducts in adult specimens show periductal 
inflammatory reaction. When ducts are found 
in patients having anal cryptitis, this incidence 
of periductal inflammation reaches 72 per cent. 
These ducts may provide pathways for spread 
of infection and it is conceivable that ischio- 
rectal abscess might have such a pathogenesis. 
Equally possible is the development of anal 
fistula, the predilection of which for the pos- 



36 


Kratzcr — Anal Ducts 



lO II 12 

Fig. 10. Duct still in submucosa and about to penetrate muscle. X 75. 

Fig. h. Duct penetrating muscle. X 75. 

Fig. 12. Duct has penetrated muscle. X 75- (Courtesy of Sure., Gynec. Ohsi., 84: 333-338, 1947.) 


terior portion of the anal canal corresponds to 
the principal site for the openings of the anal 
ducts. 

The diagram (Fig. i) indicates the amount of 
skin excised with the crypts of the posterior 
quadrant for an abscess or sinus in the midiine 
posterior to the anorectal area. Abscesses in 
other areas are handled similarly. 

A normal crypt (Fig. 2) is included for com- 
parison. It is lined with stratified squamous 
cells. Inflammatory cells are absent. 

A crypt is shown (Fig. 3) which is obviously 
the seat of disease. The epithelium is almost 
completely destroyed and there is marked in- 
filtration of Ij'^mphocytes and plasma cells. 
This process is subacute cryptitis. 

.The next photomicrograph (Fig. 4) shows a 
normal duct lined with several layers of transi- 
tional epithelium. The cells are po^'^gonal in 
shape. 

Figure 5 shows a cross section of ducts with 
a periductal inflammatory process. 

A photomicrograph (Fig. 6) is included to 
demonstrate the evidence of an acute inflam- 
matory process in the lumen of a duct. Many 
polymorphonuclear leukocytes are present. 

Figure 7 shows a duct observed in the ano- 
rectal region of a human embryo. 

The next five (Figs. 7 to ii) show some of 
the phases in the course of a duct as it originates 
m a crypt, traverses the submucosa and pene- 

rates the surrounding muscle. 


CONCLUSIONS 

A group of twenty consecutive patients with 
pararectal abscesses, representing primarj’^ and 
recurrent disease in which evidence of a definite 
primary opening could not be demonstrated, 
is presented. These abscesses apparently were 
cured by adequate drainage and removal of 
the crypts in the corresponding segment of 
the anal canal. 

A demonstration of the possible role played 
by the anal ducts in the spread of anorectal 
infection is described.. 

REFERENCES 

1. Buie, I.. A. Pr.ictical Proctology. P. 129. Phil.i- 

delphin, 1938. W. B. Saunders Co. 

2. Courtney, H. The posterior levator space. Tr. 

Am. Prod. Soc., 45; 450-455, 1946. 

3. Bacon, H. E. Anus, Rectum, Sigmoid Colon: 

Diagnosis and Treatment. Pp. 186-196. Phila- 
delphia, 1938. J. B. Lippincott Co. 

4. Hermann, Gustave and Defosses, L. C. Sur la 

muqueuse de la region cloacole du rectum. 

Compt. rend. Acad. d. sc., 90: 1301-1302, 1880. 

5. Johnson, F. P. The development of the rectum in 

the human embryo. Am. J. Anal., 16: 1-57, 1914. 

6. Lockhart-Mummery, J. P. Discussion on fistula- 

in-ano.Proc. Roy. Soc. Med., 22: 1331-1341. 1929. 

7. Harris, H. A. Discussion on fistula-in-ano. Proc. 

Roy. Soc. Med., 2: 1341-1351, 1921. 

8. Tucker, C. C. .and Hellwig, C. A., Histopa- 

thology of the anal crypts. Sure. Gynec. & OLst., 

145-148, 1934. 

9. Pope, C. E. Discussion on histopathology of the 

anal crypts. Tr. Am. Prod. Soc.% 34-51, 1933. 

10. Bremer, J. L. A Textbook of Histology Arranged 

American Journal of Surgery 



Kratzer — ^Anal Ducts 


37 


upon an Embryological Basis. Ed. 5, P. 296. 

Philadelphia, 1936. Blakiston Co. 

1 1. Morgan, C. N. Surgical anatomy of the anal canal 

and rectum. Post-Grad. M. J., 12: 287-300, 1936. 

12. Kratzer, G. L. and Dockerty, M. B. Histo- 

pathology of the anal ducts Surg., Gynec. & 

Obst., 84; 333-338, 1947- 

DISCUSSION 

Durand Smith (Chicago, III.): Dr. Kratzer 
presents a series of twenty cases of abscesses in 
which he could find no definite internal opening; 
yet each abscess was apparently cured by incision 
and adequate drainage of the abscess plus excision 
of the anal crypts and intervening skin between the 
crypt and the abscess. In effect, he performed an 
immediate fistulectomy, 

I believe that most of us have had similar ex- 
periences in the treatment of acute infections 
about the anus and rectum. This is particularly 
true if the abscess is an initial one. Even in recur- 
rent abscesses and anal fistulas of long duration it 
may not be possible to demonstrate any visible 
connection between the crypt and the external 
opening. 

In reviewing the last fifteen cases of abscesses in 
my own practice I was able to demonstrate to my 
own satisfaction only two cases in which I believed 
there was a definite sinus connecting with a crypt. 
In both of these cases the abscesses were recurrent 
ones, yet removal of the corresponding anal crypt 
and intervening tissue resulted in a clinical cure. 
Dr. Kratzer discusses very thoroughly the histo- 
pathology of the anal crypts and ducts. He further 
considers the role the crypts and ducts play in the 
development and spread of perianal infections. 

I am sure that those of us who practice procto- 
logic surgery are convinced of the part the crypts 
and ducts play in the spread of infection. The crypt 
has been aptly described as the gateway to anal 
Infection. Most of our surgical procedures for the 
treatment of lower rectal and anal infections have 
been specifically designed with the view of eradi- 
cating this source of infection. Cryptectomy, 
excision of anal fissures, and fistulectomy are based 
on the principle of removing this gateway of 
infection. 

From the histologic study of perianal tissue one 
can readily visualize how infections may spread 
from the crypt by way of the anal ducts. Con- 
struction of ducts from serial sections as has been 
done by Hill and more recently by Coleman, 
Nesselrod and Anson show how very complex these 
ducts may become and to what extent they may 
ramify into the surrounding tissue. 

While the majority of infections may start in 
this manner, all perianal abscesses do not neces- 
sarily have their origin in the crypts. I have had 
three cases of abscesses, all of them in diabetics 
who were very poorly controlled, which responded 

January, 7950 


to incision and drainage alone. Because of the poor 
physical condition of these patients no attempt 
was made to perform any definitive surgery. In 
none of these cases was I able to demonstrate any 
internal opening. I am convinced that these 
abscesses were the result of infections developing 
in the skin and not from or through the crypts. 
Two of these patients have had no recurrence in 
three and two years, respectively. One had another 
abscess well out in the opposite buttock which also 
promptly responded to incision and drainage. 

Dr. Kratzer poses the question whether these 
abscesses and draining sinuses would have been 
eradicated by incision and drainage alone. The fact 
that 60 per cent of his cases had had previous 
surgery would suggest that drainage alone is of 
little value. 

WiLFORD L. Cooper (Lexington, Ky.): It is a 
pleasure to discuss this paper because of its excel- 
lence and its application to the study of the pa- 
thology of this region of the body. This investigative 
work into proctologic problems which are not 
classical is to be admired. The fistula with the clearly_ 
defined primary and secondary opening is an impor- 
tant problem but the group of cases without a 
primary opening offers a distinct problem. Who 
among you have not been confronted with the dis- 
appointment and sometimes utter dismay which 
comes after a long and futile search for the primary 
opening of a fistulous tract? The surgical manage- 
ment described by Dr. Kratzer not only removes 
the much feared division of the sphincter muscle but 
offers a proven successful method of managing such 
cases. 

I am of a similar opinion in believing that the 
spread of infection from the crypts in many cases 
cannot be explained fully on the basis of lymphatic 
spread alone. The anal ducts are performed tubular 
structures which open into the crypts of Morgagni. 
Infection of the ducts is a definite factor in the 
genesis of anal fistula and pararectal abscesses. The 
question of why this region is so frequentiji the site 
of an inflammatory process may well be answered 
by a knowledge of these structures. A natural in- 
cubator is formed by the narrow anal ducts. They 
are also subject to all of the traumatic influences 
which attack the rectal outlet by communicating 
with the bowel lumen as they do. They afford a 
ready avenue for infective organisms such as colon 
bacillus, staphylococcus, streptococcus, gonococcus 
and others. Bacteria may possibly penetrate through 
small defects in the epithelial lining of the ducts and 
gain entrance into the surrounding fatty, muscular 
or fibrous tissue. An abscess or fistula may result. 

It is a common experience with fistulous epithelial 
tracts in any region of the body that the tract must 
be removed entirely to effect a cure. The existence 
of these preformed epithelial tubules may explain 
the clinical fact that so-called cryptitis and anal 



38 


Kratzer — Anal Ducts 


fistula do not heal as a rule by conservative thera- 
peutic measures. In some inflamed anal ducts areas 
of the inner cpitiielial lining may he preserved and 
regeneration of the epithelial wall may take place 
after subsidence of an infection. Tliis will prevent 
obliteration of the ducts by scar tissue. The ducts 
may then stay open and give entrance to a recurrent 
infection. Complete healing usually does not occur 
as long as a part of the epithelial lining remains. 
The whole tract should be removed to obtain a 
permanent cure. This might raise the question, If 
penetration by the anal ducts takes place into the 
fibers of the internal sphincter muscle or between 
the external and internal sphincter muscles, why 
not more trouble from that part of the anal duct 
which is not removed when the sphincter muscle 
fibers are not divided? 

' The anal ducts may vary greatly in number, in 
depth of penetration, in direction of penetration 
and in canalization, all of which influence the 
location of an abscess. Lateral penetration may 
extend to or througli the sphincter muscles. Pene- 
tration may take place cephalad or caudad as well 
as laterally. Some ducts extend only to the sub- 
mucosa while others extend deeper. Canalization 
does not necessarily progress peripherally as some 
investigators have demonstrated that the ducts may 
not be canalized proximally and distally but canalized 
in the more central part. Surrounding the uncanalizcd 
segments there may be no evidence of inflammation. 
This may lead to a variable location of pararectal 
abscesses. The anal ducts play an important role in 
the genesis of pararectal abscesses and are of great 
clinical significance. 

A prominent step forward in understanding the 
problem of infection in this area with abscess forma- 
tion and its surgical management has been taken 
and Dr. Kratzer is to be commended on this work. 

Rudolph V. Gorsch (New York, N.Y.): The 
pathogenesis of pararectal abscess is a controversial 
and very interesting subject and Dr. Kratzer is to 
be commended on his investigations concerning 
the anal ducts. We must remember that the 
urologists would not entirely agree with us in our 
etiology of these abscesses. A small percentage of 
them originate from foci in the urogenital tract. 

There are several interesting and as yet unex- 
plained factors regarding anorectal infection 
which presumably arise in the anal ducts which are 
present throughout life. These include the much 
greater incidence of these abscesses in the third 
and fourth decades and the comparatively greater 
incidence of the ischiorectal abscess in the female, 
five to one in the male. 

It may be important to point out that the ducts 
may extend into the even through the anal muscu- 
lature at different levels. This is significant to 
thdr adequate drainage. 

Claude C. Tucker (Wichita, Kan.): When 


Dr. Hcllwig and I first presented our paper on anal 
ducts entitled “Histopathology of Anal Crj-pts” 
in 1933 before this section we stressed the fact both 
European and our early American writers paid 
little attention to the pathology of anal crypts. 
Lockhart-Mummery stated enlarged papillae pro- 
duce neuralgia of the bowel but no mention was 
made of their pathology. By a special strain we 
found myclcnatcd nerves running to the tip of the 
anal papillae. At the tip we found Meissner’s 
tactile corpuscles explaining the extreme sensitivity 
of the anal papillae. 

Our histologic studies of the anal crypts revealed 
that the crypt itself was not the scat of infection 
but that the pathologic process was confined to 
anal ducts and that these ducts were performed 
structures and not the result of an ulcerous process. 

We found these ducts sometimes extending into 
the internal sphincter and that infection productive 
of fistulas incubates in these ducts which lead to 
glands between the internal and external muscles. 

The only time we have found the crypts of 
Morgagni involved were of gonococcus origin in 
the female due to the fact that on defecation the 
rectum is somewhat inverted and the anal crypts 
and ducts are bathed in the vaginal secretion. 
These ducts have their origin from the transitional 
epithelium of the intermediate zone and are lined 
by transitional and columnar epithelium thus 
subjected to the same favorable condition of infec- 
tion as the paraurethral and prostate gland. 

It is our plea that all visible ducts and crypts be 
removed at operation for after sectioning many 
thousands of specimens we have found either acute 
or chronic infection in these glands. Although all 
the visible glands have been removed, it is no 
indication that others may not become infected 
and pop up. This we explain to the patient before 
surgery. We insist on removal of any glands that 
become infected following operation and have 
found our patients to be very cooperative in this 
matter. 

I am very glad to have heard Dr. Kratzer’s 
splendid paper on anal ducts. We believe that 
proctologists are becoming more mindful of the 
role ducts play in anorectal pathology and will 
continue to become more so when there is a closer 
relationship established between the proctologist 
and pathologist. 

Malcolm R. Hill (Los Angeles, Calif.): Dr. 
Kratzer’s paper is certainly one worthy of com- 
mendation. The evolutionary idea that anal glands 
are vestigial remains was challenged in our previous 
studies. We proceeded along lines similar to Dr. 
Kratzer's in the study of the embryos as well as 
adult and stillborn specimens. 

I am very happy to notice that the doctor con- 
cludes in his study that 10 per cent of individuals 
have a secretory gland element present. He also 


American Journal oj Surgery 



Kratzer — Anal Ducts 


39 


mentions that 50 per cent of adults have the duct 
element. It is true that there is a wide variation 
in the adult. 

We also observed that there is an e.xtremely wide 
variation in the histologic development at the time 
of gestation in the tissues of the anorectal canal. 
This histologic development undoubtedly carries on 
postnatally. In those specimens containing anal 
ducts and glands we found that the large percentage 
of these elements extended caudad whereas some 
extended cephalad. This latter phenomenon gives 
reason for the extension of abscesses into the pelvic 
areas. Mention was also made of the isolated 
glands as a source of pyogenic infection carrying 
the potentiality of the isolated abscess and fistula 
which has no connection with the anorectal canal. 

Tucker, Helwig, Nesselrod, Kratzer and others 
are to be congratulated as well as encouraged to 
carry on investigation for the furtherance of 
medical and surgical knowledge of this important 
histopathologic entity. This wonderful organization 
of which you and I are privileged to be members 
certainly is helping to fulfill this objective. 

W. B. Gabriel (London, Eng.): I quite agree 
with the previous speakers on the importance of 
these anal crypts and ducts. We find histologic 
evidence of their presence in quite a large propor- 
tion of perianal abscesses. My view personally is 
that there is always an internal opening which 
must be found. I think if you will take a pair of 
scissors and excise a V of tissue between the 
abscess and the anal canal, you will excise the 
tract. Very often I think you can find the tract 
most easily by using a little curved probe from 
within outward. My view is that there is always a 
direct tract between the abscess cavity and the 
anal canal which must be either e.xcised or laid 
open. 

Guy L. Kratzer (closing): I am very happy 
about the amount of discussion this paper stimu- 
lated. I am quite certain that we have not heard 


the last of the anal ducts. I think this is just the 
beginning. 

. I shall try to answer some of the questions that 
were posed by Dr. Cooper, Dr. Gorsch and Dr. Hill. 

Dr. Cooper inquired about the intervening tract 
after removing the crypts and also draining the 
abscess. He wanted to know what would happen 
to the remaining ducts in the sphincter. I can only 
point to a paper that was presented last year at this 
meeting in reference to the cure of rectovaginal 
fistula in which the internal opening is removed and 
the mucosa slid down over that opening and 
attached to the internal border of the external 
sphincter muscle. That is a procedure which works 
and I think it can be compared to what I have done 
in curing these perirectal abscesses, namely, 
remove the crypts and drain the cavity. I have 
done this and obtained results. 

Dr. Gorsch presented several interesting prob- 
lems; I am sure I will not be able to answer all of 
them. He asked why these perirectal infections are 
more common in the third and fourth decades of 
life. I think all infections are more common at that 
stage of life. I think all of us begin to disintegrate 
at that time. I am not so sure that we attribute all 
of these infections to enteric infections. I believe 
that many of them, as mentioned by Dr. Smith, do 
begin in the skin around the anus. 

After all, no discussion on anal ducts would be 
complete without remarks by Dr. Tucker. I think 
he started the whole thing. Dr. Hill talks about 
pelvic abscesses, possibly beginning as infection 
in anal ducts, going cephalad through the levator. 

I believe Mr. Gordon Watson from London was the 
first to mention that. I have no pictures to prove it 
but I believe that could happen. I am very much 
honored to have Mr. Gabriel discuss this paper. 

I believe I tried to answer all the questions 
except the following: Why do infections occur 
more frequently in males? I am not so sure about 
that. I do not know why there should be a sex 
difference. 




January, ig^o 



HEMORRHOIDS 

ETIOLOGY AND PATHOLOGY 

O. C. Gass, m.d, and Jack Adams, m.d. 
Chattanooga, Temiessee 


T he material for this paper was gathered 
during the observation and treatment of 
4,000 conseeutive anorectal patients seen 
in private practice during the past four years. 
The purpose of this paper is to establisli the 
fact that hemorrhoids arc a lierniation of the 
modified anal skin and rectal mucous membrane 
through the musculofascial anorectal opening 
with or without involvement of the submucosal 
ple.\us of vessels; also that hemorrhoids arc not 
mere varicosities and should not be treated as 
such. 

Bacon* defines hemorrhoids as varicose 
dilatations involving one or more radicles of 
the hemorrhoidal veins. According to Buie,- 
“ Hemorrhoids are tumors which are made up 
of collections of varicose veins; .... which 
occur beneath the mucous membrane of the 
lowest rectal segment and beneath the skin of 
the anal canal and perianal margins.” Hip- 
pocrates^ describes, hemorrhoids as vascular 
tumors of the rectal mucous membrane. 

A brief review of the embryology, anatomy 
and terminolog}^ of the lower bowel will aid in 
this discussion. Shortly after the third week of 
embryonic life the entodermal cloaca descends 
and the ectodermal cloaca or proctodeum be- 
comes invaginated forming the anal pit. The 
entodermal cloaca and the ectodermal cloaca 
approach each other and blend to form the 
anal plate or anorectal membrane which is 
absorbed during the eighth week leaving a free 
communication between the rectum and the 
anus. The line of junction between the rectum 
and the anus is called the pectinate or ano- 
rectal line.'* 

The rectum is defined as that portion of the 
gut which transverses the pelvis from the reflec- 
tion of the peritoneum to the levator muscles, a 
distance of approximately 12 cm. The anus 
is the terminal 3 cm. of the intestinal tract 
extending from the anorectal line to the aper- 
ture. The lumen of the anus should properly be 
referred to as the anal canal and the terminal 
opening as the anal aperture. It is only the anus 


and not the canal that can have fissures, 
hemorrhoids and other pathologic processes. 

With an understanding of the fact that the 
rectum and anus arc the terminal segments of 
the intestinal tract and that the levator mus- 
cles, sphincters, fascia and skin are a part of 
the abdominal wall or floor, it is obvious that 
any protrusion through the sphincters is a 
hernia and not a prolapse or procidentia. 
Prolapse or procidentia is a falling or ptosis of 
one viscus in relation to another viscus whereas 
a hernia is defined as a protrusion of an organ 
or tissue through an abnormal opening. It 
has been our experience that so long as the 
musculofascial supportive structure of the 
anus is intact no protrusion is possible and no 
hemorrhoids or hernia will be found. 

The hjTsertrophicd perianal folds of pruritus 
ani, sentinel pile of Brodie, inflammatorj’- skin 
tags and anterior folds following delivery are 
not true hemorrhoids and not subject to the 
criteria for hemorrhoids. 

\Vhy certain people develop hemorrhoids 
while others do not, how they can be most 
satisfactorily treated and, most important, how 
hemorrhoids can be prevented are important 
problems. Several generalized obsert’^ations or 
conclusions can be made from the history, 
e.\amination and treatment of our cases as to 
the development of hemorrhoids. They are as 
follows: 

First, tonicity of the anal sphincters largely 
controls the production of hemorrhoids. There 
are exceptions to this rule. Nevertheless, in our 
experience hemorrhoids seldom develop in the 
constipated individual with a spastic or hyper- 
tonic sphincter muscle. It is true that these 
patients constitute the larger proportion of our 
office practice and possibly our hospital 
surgical ser\dce. Their chief complaint is 
usually piles or hemorrhoids; but when an 
adequate history is taken and examination 
made, it is found that the3'^ actually consulted 
the proctologist because of one or more of the 
numerous pains or symptoms resulting from 
constipation and anal trauma. This type of 

American Journal oj Surgery 


40 


Gass, Adams — Hemorrhoids 


41 


patient usually has an anal canal through 
which one can barely insert a finger without 
causing severe pain. Further examination 
reveals the source of complaint to be contrac- 
tion of the anus due to absence of the dilating 
effect of formed stools or the sequelae of anal 
trauma and infection such as ulcer, crj’^ptitis, 
fistula or abscess which are often associated 
with constipation and laxative habit. There 
may be a pile of Brodie, inflammatory skin tag 
or a thrombotic process but rarely protrusion' 
of the anal or rectal mucosa. Internal hemor- 
rhoids are seldom apparent even with severe 
straining. 

Hemorrhoids have been found to be a disease 
of the individual with a sphincter tonicity vary- 
ing from normal to complete atonia. This is 
contrary to the popular opinion of both the 
profession and the laity. The more atonic the 
anal sphincter the greater the protrusion, 
herniation or hemorrhoids. 

If the patient has a normal anorectum, one 
finger can be inserted with ease, yet the sphinc- 
ter muscles contract snugly around it. The 
development of hemorrhoids in such an indi- 
vidual usually runs the typical course. He may 
begin to notice a little protrusion or painless 
bleeding .with evacuation about the third 
decade of life. This protrusion may gradually 
follow each evacuation and require manual 
replacement. Progression results in protrusion 
with lifting, straining or stooping. The patient 
may discover that by lying down an hour or so 
after evacuation the hemorrhoids will reduce 
easily, so he deliberately changes his time of 
evacuation to bed time. Strangulation, throm- 
bosis or complete divulsion of the sphincter 
with constant soiling of the patient’s clothing 
eventually forces him to consult a physician. 

Second, hemorrhoids were frequently found 
in individuals with other signs of weakened 
supportive or connective tissue. In the male 
inguinal hernia and in the female procidentia 
of uterus, rectocele or cystocele are often 
associated. In either sex a proctosigmoidoscopy 
often reveals a prolapsed or redundant mucosa 
of the rectum frequently obliterating the 
valves of Houston. 

Third heredity is a factor in the production 
of hemorrhoids. People do not inherit hemor- 
rhoids but the conducive personality, nervous 
system and tjqae of tissue is inherited. It is a 
common experience to have operated upon 
several members of the same family with large, 

January, ig$o 


herniating, protruding hemorrhoids which have 
required manual reduction after each evacua- 
tion. Constipation also occurs in families in 
whom the occurrence of hemorrhoids is un- 
common. The influence of environment and 
living habits are important factors in these 
cases and probably outweigh the influence of 
tissue inheritance in many instances. 

Fourth, all forms of treatment and all 
operations for hemorrhoids are designed (and 
rightly so) and executed for the prevention of 
herniation of the rectal and anal wall and not 
for the obliteration of veins as in the case of 
varicosities of the extremities. When injection 
therapy is used, injections directly.into the vein 
are not advocated. Injections are made into the 
bulging mass. They are perivascular rather 
than intravascular. Good results depend on the 
resultant inflammatory reaction and the amount 
of scar tissue subsequently produced with its 
anchorage effect. Surgical procedures are 
designed to remove the bulging tissue, increase 
the sphincter tone and decrease the lumen of 
the anal canal. 

The treatment of hemorrhoids does not differ 
radically from the treatment of abdominal 
hernia in any other region except that the anus 
must function properly. If the sphincter is 
defective, such as that resulting from the 
laceration of childbirth, restoration of con- 
tinuity may be all that is necessar3^ However, 
in such conditions the mucosa of the rectum 
has usually protruded so much and so often 
that its collagenous attachment has been 
loosened as well as that of the perianal tissue. 
Resection of the redundant tissue is therefore 
advisable. 

The anorectal tissue has a definite tendencj’’ 
to loosen and herniate first in the left lateral, 
right anterior and right posterior phases. A 
liberal resection in these three locations is 
usually sufficient. The object of surgery, how- 
ever, is to remove all excessive and loosened 
mucosa of the lower rectum, modified anal skin 
and ’■ perianal skin necessary to restore the 
region to as nearly normal as possible when 
healing is completed. The interposed remaining 
tissue will then be anchored on both sides with 
scar tissue resulting from the healing process. 
No stricture formation or bulging of the lower 
rectum into the anal canal should result. 
Patients with large hemorrhoids frequently 
complain of incontinence of the anal sphincters 
with constant soiling and inability to control 



42 


Gass, Adams — Hemorrhoids 


gas. The constant herniation of these struc- 
tures througli the spliincters followed by 
repeated manual reduction results in a chronic 
divulsion of the sphincter muscles. Proper 
resection in two or more locations so as to 
restore the anorectal lumen to normal will 
result in the prompt return of normal sphinc- 
teric action and continence. 

No stricture has occurred following operation 
in our series and postoperative edema with 
resultant skin tag formation rarelj' occurs. 
These results are attributed to a scientific 
approach to the problem plus gentle treatment 
of the tissues of the region to avoid trauma. 
The Pansier operative anoscope has been found 
to be more useful in operations of this tj^pe. 

Several discussions of the pathology of 
hemorrhoids are given in the literature. 
According to Boyd® a hemorrhoid consists of a 
cluster of greatly dilated venules covered by 
mucous membrane or skin. Bell" includes a 
microscopic description, “Microscopic exami- 
nation of a hemorrhoid reveals a cluster of 
dilated veins, many of which are often throm- 
bosed.” Moore® described the pathologic changes 
as dilatation, adventitial fibrosis and throm- 
bosis. The incompleteness of these descriptions 
is probably due to inadequate operative 
specimens which have been available to the 
pathologist. The examination of an acute, 
strangulated, dilated and thrombosed pile will 
closely resemble such a description. Recently 
200 consecutive surgical specimens were sent 
to the pathologist for a careful, detailed exami- 
nation. The outstanding feature of the sections 
studied was the loose and fragmented nature 
of the collagenous connective tissue stroma 
which showed a loss of its usual compact and 
even staining architecture. Many of the vein 
walls showed a compensatory thickening. The 
walls of other veins appeared intact or moder- 
ately thin. These sections were identical in 
appearance with sections made from cj^stoceles 
and rectoceles. It was only after venous 
thrombosis with its following organization and 
scarring, a relatively late phenomenon in the 
natural history of the process, that the usually 
described pathologic picture of hemorrhoids 
was observed. 

COMMENTS 

It seems evident that hemorrhoids like any 
other pathologic process must have a natural 


history. In the early stages gross examination 
reveals loose, perianal tissue in either or both 
lateral phases of the anus. Microscopicall}’’, the 
earliest change noted is a fragmentation and 
giving away of the collagenous connective 
tissue stroma about the veins. This is accom- 
panied by a compensatory hypertrophy of the 
vein walls. As the process progresses, an 
exaggeration of thq breakup of the connective 
tissue stroma is associated with a fragmentation 
of the striated muscle fibers. There is a striking 
absence of any inflammatory reaction and no 
attempt at scar tissue formation takes place 
until late in the process. Further progression 
reveals a breakdown of the anal and perianal 
tissue with a divulsion of the musculofascial 
structures of the anus. Microscopic sections of 
this stage show the space left by the breakup 
of the connective tissue stroma to be partially 
occupied by veins which are beginning to 
dilate. After herniation of the rectal wall takes 
place the microscopic picture is one of complete 
breakup of the stroma and further dilatation 
of the veins. Even at this time the compensa- 
tory hypertrophy of the vein walls is still 
present. Finally the process develops into the 
familiar strangulated and herniated hemorrhoid 
which microscopically shows the textbook 
picture of thrombosed veins undergoing organ- 
ization and scar-tissue formation. 

SUMMARY 

During a four-year period 4,000 private 
patients were examined. Of this number 1,396 
or 28 per cent were found to have hemorrhoids 
of sufficient size and/or symptoms to require 
treatment; 688 or approximately 50 per cent 
were subjected to hemorrhoidectom}'. Detailed 
microscopic sections were made on specimens 
from 200 consecutive patients. 

Contrary to the usual description, the 
pathologic section demonstrated a loose and 
fragmented nature of the submucosal, col- 
lagenous, connective tissue stroma as the 
fundamental early lesion. The vein walls 
showed relatively little change until in the 
natural history of the process at which time 
thrombosis and organization began to occur. 
This suggest a giving away of the supportive 
structures rather than a weakening and 
thinning out of the vessel walls as the initial 
pathologic change. 

The success of either the surgical or injection 


American Journal of Surgery 



Gass, Adams — Hemorrhoids 


43 


treatment of hemorrhoids depends on the 
correction of the herniation or protrusion and 
not on the obliteration of varicose veins. 

Embryologicallj', anatomically, physicologi- 
cally and proctologically, the tube from the 
anoreetal line to the terminal orifice should be 
considered as the anus, its lumen the anal canal 
and the terminal orifice as the anal orifice or 
aperture. A protrusion of the rectal mucosa 
through this aperture is correctly called a 
hernia. 

Anorectal herniation or hemorrhoids are not 
the result of constipation but a disease of those 
with normal bowel habits whereas other infec- 
tions and traumatic diseases of the lower 
rectum and anus are the results of constipation 
in the majority of patients. 


REFERENCES 

1. Bacon, Harry E. Anus, Rectum, Sigmoid Colon. 

Diagnosis and Treatment. 2nd ed., p. 442. 
Philadelphia, 1941. J. B. Lippincott Co. 

2. Buie, Louis A. Practical ProctoIog3'. P. 163. Phila- 

delphia, 1938. W. B. Saunders Co. 

3. Dorland, W. a. Newman. The American Illustrated 

Medical Dictionary. 18th cd. Philadelphia, 1938. 
W. B. Saunders Co. 

4. Bacon, Harry E. Anus, Rectum, Sigmoid Colon. 

Diagnosis and Treatment, and. ed., pp. 1-5. 
Philadelphia, 1941. J. B. Lippincott Co. 

5. Barrett, Channing W. Anatomj’ and embrology 

of the anus in relation to the pelvic floor. J. 
Internal. Coll. Surg., 10: 306-316, 1947. 

6. Boyd, William. Text Book of Pathology. 4th cd., 

p. 520. Philadelphia, 1943. Lea & Febiger. 

7. Bell, E. T. Text Book of Pathology. 6th ed., p. 553. 

Philadelphia, 1947. Lea & Febiger. 

8 . Moore, Robert A. Text Book of Pathology. P. 

1002. Philadelphia, 1944. W. B. Saunders Co. 


€ 1 ^ 


Januaryr, 7950 



THE PRESENT STATUS OF INJECTION TREATMENT OF 

INTERNAL HEMORRHOIDS 


Robert V. Terrell, m.d. and C. C. Chewning, Jr., m.d. 

Richmond, Virginia 


T ME injection treatment of internal hem- 
orrhoids remains a controversial subject 
although it has been practiced since 
1871.' After our own experience of thirteen 
years we are more enthusiastic than ever about 
the results obtained from the injection method. 
Discussions with other proctologists have con- 
vinced us that many are not obtaining the best 
results possible with this method and a few 
have discontinued its use. Therefore, a brief 
summary of our personal experience with the 
injection method of treatment as well as that 
of the membership of the American Proctologic 
Society should be of general interest. 

Selection of Cases Jor the Injection Method. 
In our practice approximately 80 per cent of 
patients examined have hemorrhoids. Of these 
25 per cent are the internal variety and are 
suitable for injection. Some proctologists main- 
tain that surgery is necessarj' for the cure of 
all patients with hemorrhoids and do not use 
the injection method of therapj'. This attitude 
results in many avoidable operations with at- 
tendant economic hardship to the patient and 
in the strain of hospital facilities already in- 
adequate to meet the demands of the public. 
Many patients whose only symptom is oc- 
casional bleeding have small or medium-sized 
internal hemorrhoids; and while they do not 
require surgery they should receive some type 
of treatment more efficient than the use of 
salves or suppositories. The injection method of 
treatment occupies a therapeutic position be- 
tween surgery and the use of such topical 
medications. Many patients have an unreason- 
able dread of surgery as well as the conviction 
that surgeons like to cut; therefore, a reputa- 
tion for curing piles without an operation is of 
great advantage to the physician. 

The vast majority of patients with internal 
hemorrhoids will be benefitted by Injection 
treatments; and when uncomplicated internal 
hemorrhoids are selected for such treatment, a 
symptomatic cure may be expected. The best 
results will not be obtained in those patients 
giving a history of anal protrusion requiring 


digital replacement over a long period of time. 
In such cases varying degrees of fibrosis within 
the hemorrhoid greatly reduce the effectiveness 
of the injection method. Size is not a contra- 
indication to injection therapy. For permanent 
cure of properly selected patients treatments 
should be continued until the physician has 
observed that the hemorrhoidal masses have 
disappeared entirely. When treatments are 
discontinued as soon as the patient is free of 
sj'mptoms, a recurrence may be expected. An 
accurate diagnosis can be made in most cases 
on the patient’s first visit bj" a careful historj- 
and physical examination including the passage 
of the sigmoidoscope. The pathologic findings 
and tire indicated treatment are then explained 
to the patient in simple language. If the patient 
has only internal hemorrhoids, he is informed 
that the injection method is the desirable 
treatment; but if external hemorrhoids, anal 
fissure, fistula, abscess, suppurative cryptitis, 
anal stenosis or polj'pi are also present, an 
operation will be necessary for his permanent 
relief. 

One of the greatest advantages of the injec- 
tion method of treatment is that it can be safel}'^ 
and effectively used for poor risk patients on 
whom surgery is undesirable such as those with 
serious heart disease, late pregnancy, diabetes, 
insanity, senility and apoplexy. Thus the 
proctologist not willing to administer the injec- 
tion treatment denies this pathetic group of 
patients the relief they have every right to 
expect. The injection of internal hemorrhoids 
will usually benefit the patient with such non- 
surgical conditions as pruritus ani, superficial 
anal fissure and certain cases of cryptitis. In 
our experience the elimination of internal 
hemorrhoids by injection has also lessened the 
frequency and severity of attacks of acute 
recurring external thrombosis. In actual prac- 
tice we treat by injection .many patients with 
such minor complicating disorders as hyper- 
trophied anal papillae and external hemor- 
rhoidal tags. The recurrence rate in this group 
is higher; but when symptoms do recur, the 

American Journal of Surgery 


44 



Terrell, Chewning — Injection of Internal Hemorrhoids 


45 


majority of patients prefer periodic injections 
to surgery. There will always be a few indi- 
viduals who resolutely refuse surgery in spite 
of our advice. For many of these injections will 
afford some measure of relief. 

Strangulated hemorrhoids require surgery 
but in many patients the prolapsing hemor- 
rhoids can be replaced within the rectum. Then 
injections may be given at a higher level than 
usual and a T-binder may be applied tempo- 
rarily to hold them in place. When the prolapse 
can be controlled in this manner, surgery may 
be delayed until the edema and inflammation 
subside. The injection method is our treatment 
of choice in rectal prolapse of infants and 
children. Rarely are more than one or two 
injections required to produce symptomatic 
cure. 

Technic and Plan of Treatment. The technic 
of the injection of hemorrhoids is not difficult 
although a certain amount of manual skill and 
dexterity is ‘essential. When the injection is 
made by an experienced proctologist, the 
results are usually good. Serious complications 
may result when it is boldly used by the inex- 
perienced or ignorant. The objective of the 
injection treatment of hemorrhoids is the 
gradual obliteration of the hemorrhoidal tumor 
without the production of a slough. Although 
many different sclerosing chemicals have been 
advocated for this purpose, our experience is 
largely limited to quinine urea hydrochloride. 
Since World War n we have used quinuride* 
which is a 4.5 per cent solution of anhydrous 
quinine and urea adjusted to a pH of 2.6 with 
hydrochloric acid. Quinuride is more efficient 
than any other preparation we have used and 
is as safe. The results have been satisfactory 
and there have been no complications. 

No particular preparation of the patient is 
necessary before treatment but it is helpful if 
the rectum has been previously emptied by 
normal defecation or an enema. The head mir- 
ror and Brinkerhoff anal speculum are used 
with the patient in a left Sims’ position. A 
22-gauge spinal needle on a small syringe 
is satisfactory for injecting the solution. 
The injection of a small amount of quinuride 
into an internal hemorrhoid produces an im- 
mediate hemostatic effect which is followed 
by a fibrous tissue infiltration. The proctologist 
can observe the hemorrhoid become progres- 
sively smaller by giving repeated small injec- 
tions at intervals of about two weeks until in 

* Manufactured by the Acme Scientific Company. 

January, ig$o 


many instances it finally’ disappears entirely. 
A slough can be produced by injecting an 
excessive amount of the solution, by using too 
strong a solution or by making the injection 
too close to the mucosal surface. A skilled 
proctologist will have little difficulty in avoid- 
ing this complication. The injection of internal 
hemorrhoids is practically painless and requires 
no anesthesia. In our technic a few drops of 
quinuride are injected into the center of each 
internal hemorrhoid at each visit. A total dose 
at any one visit rarely exceeds 1.5 cc. Swabbing 
the mucosal surface with an antiseptic does not 
seem important, nor do we aspirate to deter- 
mine if the needle is in the lumen of a vein. The 
solution must be placed high enough above the 
mucocutaneous line to prevent seepage of the 
injected fluid beneath the anal skin. Bleeding 
at the site of needle puncture is reduced if the 
needle is allowed to remain a few seconds and 
then is turned slowly as it is withdrawn. The 
injection is made under direct vision and care 
is taken not to overdistend the hemorrhoid. 
Blanching should not occur; and when it does, 
a slough may result. One to two weeks is the 
optimal interval between treatments but this 
may be varied to suit the patient’s convenience 
or the condition of the hemorrhoids. It may be 
desirable to give the. first two or three treat- 
ments at closer intervals if internal hemorrhoids 
are very large. Occasionally patients coming 
from a distance take up a temporary residence 
in a local hotel and receive treatments on three 
or four consecutive days. Induration of the 
hemorrhoid may follow such intensive treat- 
ment, a condition which is rarely encountered 
when treatments are given at longer intervals. 
To prevent sloughing injections should be 
deferred until induration has subsided. Four 
to ten treatments are adequate for the vast 
majority of patients who should return for a 
check-up examination in six months. A pressure 
dressing is applied to the anus for a few hours 
after the injection when hemorrhoids are very 
large and prolapse easily and the patient is 
advised not to defecate for twelve to twenty- 
four hours. Strangulation as a complication of 
the injection method of treatment has been 
almost completely eliminated by this precau- 
tion. Although the injection itself is painless, 
most patients will experience moderate ano- 
rectal discomfort or a feeling of heaviness com- 
ing on thirty minutes following the treatment 
and lasting an hour. They are advised to be off 



46 


Terrell, Chevvning — Injection of Internal Hemorrhoids 


their feet for this period after whicli normal 
activities may be resumed. 

Complication!:. The only alarming com- 
plication observed by us following the injection 
of quinine urea hydrochloride has been the rare 
occurrence of quinine sensitivity with vaso- 


^EARLY. AND LATE SY.Min'OMATIC RESULTS 
FOLLOWING INJECTION THERAPY 
Although our c.vpcricnce witli the injection 
method of treatment of internal hemorrhoids 
has most favorably impressed us with the 
results obtained, we have not until this time 


Table i 

EARLY SYMPTOMATIC RESULTS OBTAINED BY INJECTION OF QUINURIDE IN SEVENTY-FIVE 
consecutive CASES OF MEDIU.M AND LARGE INTERNAL HEMORRHOIDS 


{ Bleeding arrcisted after one injection 39 

Bleeding arrested after two injections 1 

Bleeding arrested after three injections 1 

/ Bleeding arrested after first injection 31 

\ Bleeding arrested after second injection 1 
Bleeding and protrusion — No. of cases 34 \ Protrusion corrected after first injection 23 

/ Protrusion corrected after second injection 9 
\Protrusion corrected after third injection 2 


motor collapse. Other less serious sensitivity 
reactions are occasionally seen. There have 
been no deaths, infections, hemorrhages, stric- 
tures, fistulas or sloughs in our series although 
on rare occasions we have observed a pinpoint 
area of necrosis in the mucosa of which the 
patient was unaware. Serious complications are 
usually the result of faulty technic, faulty 
judgment in the selection of patients for treat- 
ment, or both. Reports of serious complications 
following injection therapy are not rare in the 
literature. Campbell- and Morgan*'’ have re- 
ported serious sloughs as well as abscesses and 
fistulas following injection therapy. Kilbourne'' 
in a statistical study gathered from fifty-seven 
proctologists in America and Europe reported 
sloughs, hemorrhages and strictures following 
the use of the injection method but there were 
no deaths reported. Rolfe,’' however, reports 
no slough or other serious complications in a 
large number of patients treated at the Boston 
dispensary over a twelve-year period. Serious 
hemorrhage has been reported by Morgan.® 
Rare complications include a case of contracted 
bladder supposedly due to the use of phenol in 
almond oil as reported by Levy and Horn.® 
Gass® reports a case of mesenteric thrombosis 
(superior mesenteric artery) following the in- 
jection of internal hemorrhoids but this may 
have been coincidental rather than a complica- 
tion. The formation of oleomas as reported by 
Rosser® would be obviated by the use of a 
non-oily agent. “We have found no report of a 
^j^^^^^^attributed to the injection form of 


attempted any detailed study of a statistical 
nature. We have been aware for- a long time 
that bleeding from internal hemorrhoids can 
be stopped and that protrusion can usually be 
eliminated by one or two injections. Further, 
it has been our belief that most simple internal 
hemorrhoids can be relieved indefinitely if 
adequately treated. We believe that although 
the recurrence rate is higher after the use of 
the injection method than after a properly 
performed hemorrhoidectomy, the small num- 
ber of patients in whom symptoms of recur- 
rence do develop can usually be kept symptom- 
free by an occasional injection. 

In order that we might convey to other 
proctologists an impression of our results in 
tangible terms we have undertaken two studies; 
the first relating to the early and the second to 
the late symptomatic results following the use 
of 5 per cent quinine and urea hydrochloride 
in the treatment of uncomplicated internal 
hemorrhoids. All patients in this series had 
medium-sized or large Internal hemorrhoids; 
all complained of bleeding and many of pro- 
trusion. (Table i.) 

For an analysis of the early results we re- 
viewed the records of new patients seen be- 
ginning January i, 1948, with bleeding, or 
bleeding and protruding internal hemorrhoids 
uncomplicated by any other demonstrable 
anorectal or sigmoidal pathologic condition. 
Seventy-five cases were found and the record 
of each was examined. Notations were made as 
to whether there was bleeding, or protrusion 
and bleeding. The number of injections required 

American Journal of Surgery 



Terrell, Chewning — Injection of Internal Hemorrhoids 


47 


to render the- patients entirely symptom-free 
was- then noted. Of forty-one patients who had 
bleeding, thirtj'^-nine or 95 per cent had no 
further loss of blood after the first injection. 
One patient required two and another required 
three injections before becoming symptomless. 
Of thirty-four patients who had both bleeding 
and protrusion, the bleeding ceased after the 
first injection in thirty-one instances or 91.2 
per cent, the other three patients requiring 
only two injections. The symptom of protrusion 
was not observed again after the first injection 
in twenty-three cases or 67.6 per cent. Nine pa- 
tients or 26.5 per cent required two injections 
and two or 5.9 per cent required three injections 
to stop all protrusion. Thus in none of the 
se\’enty-fi\'e patients were more than three 
injections needed to achieve and maintain 
complete symptomatic relief during the period 
of treatment. 

The study to determine late results of the 
injection form of therapy presented a more 
complex problem. As it is difficult and im- 
practical to have many widely scattered pa- 
tients return for an examination, especially if 
the patient had experienced no anorectal 
symptoms, we decided that a simple question- 
naire would be the most satisfactory method 
of study. A careful examination was made of 
the records of every patient with uncompli- 
cated internal hemorrhoids who had been 
treated by the injection method during the 
five-year period extending from June, 1938, to 
June, 1943, and questionnaires were sent to 
each. The questions, all of which could be 
answered either yes or no, were as follows: 

1 . Have you had any rectal complaints since 
your last treatment? 

2. Have you since consulted another physi- 
cian about any rectal complaints? 

IJ You Have Been Treated by a Physiciaii 

1 . Have you had a return of the same symp- 
toms for which Ave treated you? 

2. Have you developed different symptoms? 

3. Have you required medical treatment for 
hemorrhoids or “piles”? 

4. Have you required an operation for 
hemorrhoids or “piles”? 

These questionnaires Avere mailed to 187 
patients and eighty-one replies Avere received. 
A feAV of the patients had died, many had 
moved during the Avar and postAvar years, so 
AA^e believed that a response of OA^er 40 per cent 

Januaryr, ig^o 


of the patients Avas reasonably satisfactory. 
(Table II.) 

Of the eighty-one patients fifty-six Avere 
male and tAventy-five female. The average age 
at the time of completion of the injections Avas 
50.2 j^ears. The youngest Avas a tAventy-six year 

Table 11 

LATE RESULTS OF THE INJECTION OF UNCOMPLICATED 
INTERNAL HEMORRHOIDS BETAVEEN 1938-1943 


81 Total No. of patients in series 

61 No. of patients entirely symptom-free after 

an average of 7.2 yr. 

12 No. of patients with minor or transient 

symptoms such as itching or mild dis- 
comfort; no visits to a physician required 

4 No. of patients with symptoms requiring 

treatment by a physician 

4 No. of patients having undergone hemor- 

rhoidectomy 


old man Avho has been completely symptom- 
free for seven and a half years. The oldest, a 
Avoman of sixty-nine, is noAV, at the age of 
seventy-eight, free of anorectal symptoms. The 
average number of injections given aa'us 8.5 
with a minimum of four and a maximum of 
sixteen injections. The average length of time 
since the last injection was 7.2 years. The 
answers from the eighty-one patients revealed 
that sixty-one or 75.3 per cent have had no ano- 
rectal symptoms. TavcIvc patients or 14.8 per 
cent reported minor symptoms such as itching, 
irritation or occasional slight discomfort, none 
necessitating a visit to any phj'sician. Only 
eight patients or 9.9 per cent had visited a 
physician because of symptoms of hemorrhoids 
and only four of these or about 5 per cent of 
the total have undergone a hemorrhoidectomy. 


Table hi 

EXTENT OF USAGE OF THE INJECTION METHOD AMONG 
313 AMERICAN PROCTOLOGISTS 


Percentage of Patients 
with Internal Hemorrhoids 
Treated by Injection 

No. of 
Proctologists 

Percentage of 
Proctologists 

o~i 

49 

' 5-7 

2-9 

62 

19.8 

10-24 

S' 

25.9 

24-49 

57 

18.2 

50% or more 

64 • 

20.4 


EXPERIENCE OF THE MEMBERSHIP OF THE 
AMERICAN PROCTOLOGIC SOCIETY 

A questionnaire Avas sent to the 355 active 
members of the American Proctologic Society- 
briefly to ascertain their ideas and e.xperience 



48 


Terrell, Chewning — Injection of Internal Hemorrhoids 


regarding the use of the injection method of 
treatment for internal hemorrhoids. (Table ni.) 
From tlie 313 answers recei-\"ed the following 
data were obtained relative to usage; 


Percentage of Internal 
liemorrhoids Treated 
by Injection 

1 

Number of 
Proctologists 

Percentage of 
Proctologists 

0 to I 

49 

' 5-7 

2 to 9 

62 

19.8 

1 0 to 24 

81 

25.9 

25 to 49 1 

57 j 

18.2 

50 or more 

64 

20.4 


Additional information revealed that 166 
believed a cure was obtainable in suitable cases 
by the injection method of treatment. One 
hundred sixty or 51 per cent of proctologists 
reported no complications while forty-seven 
or 1 5 per cent reported abscesses, hemorrhage, 
slough, infarction or allergic reactions and 106 
or 34 per cent reported superficial sloughs or 
other mild complications. Many volunteered 
the information that they had observed serious 
complications following the injection treatment 
done by someone else although they had not 
had such complication in their own practise. 
Various sclerosing chemicals were reported 
used; quinine urea was the most popular with 
phenol-in-oil the next most popular. A few 
stated that they are now using injection 
therapy less frequently than formerly. While 
many proctologists are still enthusiastic about 
the use of the injection therapy, a few even 
more so than ever, the over-all impression 
created by the answers received leads us to 
conclude that this method is slightly less 
popular than formerly. One of the reasons for 
this trend appears to result from the impression 
on the part of many that uncomplicated in- 
ternal hemorrhoids are relatively rarer than 
was formerly believed. In addition many 
apparently refrain from using the injection 
method because of the fear of serious com- 
plications incident to its use. 

SUMMARY 

1. The criteria for the selection of patients 
for the injection type of therapy are enumer- 
ated and the plan and technic employed are 
outlined. 

2. Certain advantages of this form of 
therapy are mentioned. 


3. Possible complications following injection 
therapy are discussed. Emphasis is given to the 
fact that serious complications can usually be 
avoided. 

4. A study of the results of our experience 
of a ten-year period is given. 

5. A resume of the experience and opinions 
of the members of the American Proctologic 
Society relative to the injection form of therapy 
is presented. 

CONCLUSION 

1. The injection method of treatment of 
internal hemorrhoids remains a controversial 
subject among proctologists. 

2. Unsatisfactory results and serious com- 
plications following injection therapy can 
usually be attributed to the improper selection 
of patients and/or to faulty technic. 

3. A high percentage of S3’’mptomatic cures 
can be achieved with injections in properh' 
selected cases. 

4. Relief of S3'mptoms can be obtained with 
the injection method of treatment in most 
cases in which the patient’s physical condition 
would make surger3'- an undue hazard or in 
which the patient refuses operation. 

5. Man3’’ proctologists fail to utilize the full 
potentialities of the injection method of treat- 
ing internal hemorrhoids. 

6. The current trend appears to indicate a 
slight waning of enthusiasm for the use of the 
injection treatment of internal hemorrhoids. 

REFERENCES 

1. Andrews, Edmund. The treatment of hemorrhoids 

by injection. M, Rec., 15: 451, 1879. 

2. Campbell, Frederick B. Serious sloughs and 

fistulous formation resulting from injection treat- 
ment. South. M. J., 38: 268-272, 1945. 

3. Gass, O. C. Mesenteric thrombosis following the 

injection treatment of hemorrhoids. Am. J. Surg., 
75: 279-280, 1948. 

4. Kilbourne, Norman J. Internal hemorrhoids: com- 

parative value of treatment by operative and by 
injection methods; a survey of 62,910 cases. Ann. 
Surg., 99: 600, 1934. 

5. Levy, S. I. and Horn, J. S. A case of. contracted 

bladder. Lancet, 1: 501-502, 1944. 

6. Morgan, James W. Catastrophies following hemor- 

rhoid injections. Calijomia & IFesI. Med., 50: 204, 
> 939 - 

7. Rolfe, William A. The treatment of internal 

hemorrhoids with quinine and urea hydrochloride. 
New England J. Med., 198: 187, 1928. 

8. Rosser, C. Chemical rectal stricture. J. A. M. A., 

96: 1762-1763, 1931. 

I 

American Journal oj Surgery 



A STUDY OF THE INJECTION TREATMENT OF INTERNAL 
HEMORRHOIDS USING 5 PER CENT PHENODIN^OIL 

A. C. Pfeifer, m.d. 

Ml. Morris, Michigan 


T he treatment of internal hemorrhoids 
falls into two categories, namely, surgical 
excision and obliteration by the injection 
of sclerosing solutions. This study is devoted 
to an evaluation of the effectiveness of injection 
therapy following the use of a single sclerosing 
solution. Controversial comparison with other 
methods of treatment and other sclerosing solu- 
tions has not been attempted. 

Many sclerosing solutions have been used to 
inject internal hemorrhoids since the middle 
of the eighteenth century but during the past 
fifteen years the agents most commonly used 
have been a 5 per cent solution of quinine and 
urea hydrochloride and a 5 per cent solution 
of phenol in vegetable oil. Kilbourne^ in 1934 
reported the results of treatment of 62,910 
patients and concluded that comparable results 
follow the use of these two solutions. He found 
no serious and few minor complications follow- 
ing the use of 5 per cent phenol-in-oil. His 
conclusions revealed that in 15 per cent of 
patients recurrence of hemorrhoids occurred 
within three years following treatment. His 
report included results following the injection 
treatment of third degree internal hemorrhoids. 

Oden® in 1940 reported good results following 
the use of 5 per cent phenol-in-oil, with relief 
of symptoms and restoration of the mucosa to 
normal after six to eight injections. 

Yaker® reported in 1944 that he had found 
injection treatment to be a method of proved 
value but only in specifically selected cases. 
This category represented 25 per cent of all 
patients seen by him. Yeomans*® reports 
prompt symptomatic relief that remained 
permanent in approximately 80 per cent of his 
cases. The injection treatment has stood the 
test of time and experience. This is agreed with 
by Yeomans, Whitney,® Bacon,* Gabriel,® 
Haskell* and many other writers. They unani- 
mously insist that a proper technic be followed 
with a specific selection of the cases. 

In the cases comprising this study 5 per cent 
phenol-in-olive-oil was used as the sclerosing 
agent except during the years 1943 to 1945 

January, ig$o 


when olive oil. was unavailable and a cottonseed 
oil (Wesson,: ^Oil) -was substituted with no 
noticeable difference in effect or result. 

Seven hundred eighty-four patients were 
treated over a period of ten years. They were 
selected from all age and sex groups. There were 
557 males and 227 females. All were patients 
with internal hemorrhoids presenting symp- 
toms of bleeding, protruding or both. Often the 
hemorrhoids were of the mixed internal- 
external type and represented all stages of 
severity from first through third degree. A 
third degree hemorrhoid is defined as one that 
will prolapse but will reduce itself sponta- 
neously. All cases of hemorrhoids complicated 
by other anorectal disorders such as cryptitis, 
papillitis, fissure, fistula, polyp, ulcerative 
proctocolitis and hemorrhoidal thrombosis 
were omitted from this series. Many of these 
patients were selected not only because their 
lesions were suitable for injection therapy but 
also because treatment by injection was the 
only method of therapy the patient could be 
offered safely or that would be accepted. These 
784 cases represent 65.4 per cent of all pa- 
tients requesting relief from uncomplicated 
hemorrhoids. 

Treatment by injection was the method 
chosen for many patients of questionable sur- 
gical risk because of the concurrence of such 
conditions as diabetes, tuberculosis, asthma, 
cardiorenal disease, advanced age, obesity, 
pregnancy and severe anemia. In like manner, 
it was offered as palliative therapy to those 
patients who refused hemorrhoidectomy for 
varied reasons. 

The complications and untoward sequelae 
following injections with 5 per cent phenol-in- 
oil are negligible. Except for an occasional 
shallow slough with inconsequential bleeding 
resulting there was none. With careful and 
proper technic, avoiding excess amount of 
solution injected, there were no complications 
to be feared. Complications often mentioned 
such as severe pain, edema, sloughing, stricture, 
abscess or oil-tumor formation® were not en- 


49 



50 


Pfeifer — Phenol-in-oil as Injection Treatment 


countered. A few of the patients with recurrence 
who later were operated upon complained of 
severe burning, itching and tenesmus. Fibrosis 
involving the pectinate area, chronic crj'pto- 
papillitis, anal sphincter muscle spasm and 
narrowing of the anal canal were attributed to 
the effect of the sclerosing solution used for the 
injections. 

The technic was uniform in all cases. After 
cleansing the rectal mucosa a spot is selected 
in the mucosa that prolapses just above each 
internal hemorrhoidal mass usuallj'' in the three 
classic locations, the right posterior, right 
anterior and left lateral quadrants. A nineteen 
gauge, inch needle is inserted beneath the 
mucosa, care being e.xercised not to enter the 
muscle; and as the loosened mucosa is lifted 
away from the musculature, the solution is 
injected slowlj' until the mucosa shows injec- 
tion stria but not blanching. The solution must 
not be Injected intravenously. The three areas 
described are injected at each treatment 
interval. The amount of solution varies from 
I to 4 cc. depending upon the degree of loose- 
ness or separation of the mucosa from the sub- 
mucosal structure. After an interval of seven 
days the second series of injections is made 
in the same manner at a lower site, usuallj' in 
the upper mid-portion of each hemorrhoid. A 
third injection series is made at the end of 
another week. The lower portion of each hemor- 
rhoid is injected, care being taken not to over- 
distend the tissue and to prevent the solution 
from infiltrating below the pectinate line. 
Overdistention at this time is prone to -occur. 
Also, infiltration of the solution beneath the 
skin of the anal canal will cause severe pain and 
often abscess and slough. After three injection 
procedures the patient is allowed to rest for a 
period of three to four weeks after which inspec- 
tion is made and further treatment instituted 
as indicated. 

Following the three injection procedures a , 
primary induration will be felt as a firm, hard 
lump involving the tissue beneath the mucosa 
throughout the hemorrhoidal area. This lasts 
from four to eight weeks. Flattening of the 
hemorrhoid and reattachment of the mucous 
membrane to the rectal musculature will be 
observed if the fibrosis is extensive enough. 
Any remaining hemorrhoidal tissue or mucosa 
capable of prolapsing is cautiously injected, 
care being taken not to inject into a previously 
sclerosed area. This procedure is repeated 
every three to four weeks until all hemorrhoids 


are obliterated. It will then be seen that the 
e-\ternal hemorrhoids have reduced in size in 
accordance with their original severity. After 
the last injection the patient is directed to 
report at intervals of three months until dis- 
charged. Following dismissal he is urged to 
return for examination every six months for 
two or three years or any time should symptoms 
reappear. 

In the 784 cases reviewed the number of 
injection procedures varied from three to 
thirteen, the average being seven. There were 
614 patients discharged as cured (78.3 per 
cent). One hundred seventy-five patients had a 
recurrence within three to nine years (21.7 per 
cent). Of the 175 patients in whom recurrence 
occurred sixty-four were cured by hemor- 
rhoidectomy and the sjmiptoms of 106 were 
controlled with repeated palliative injections. 
One hundred seventy patients discontinued 
treatment after from one to eight injections 
(average five) and never returned for observa- 
tion or final discharge. It is a reasonable 
assumption that many of these who were free 
from symptoms and showed favorable progress 
could be added to the 614 patients discharged 
as cured. This would raise the percentage of 
cures but we have no assurance that all of the 
patients discharged as cured have remained so 
in spite of a reasonably accurate follow-up. 
The number of patients (78.3 per cent) cured 
with an incidence of recurrence of 21.7 per cent 
seems as accurate and conservative a calcula- 
tion as possible. 

Of the patients discharged as cured the 
follow-up shows 1 59 to be symptom-free for 
three years, 167 for five years, 172 for eight 
years and 116 over eight years. Of those 
reporting with recurrence 129 were symptom- 
free for three years, thirt3'’-four for five years, 
ten for eight years and two over eight years. 
Seventy-four per cent of all recurrences 
occurred within three years. 

From the 175 recurrent cases sixty-four 
patients were selected for hemorrhoidectomy 
(36.5 per cent of the recurrent cases). (Table i.) 
The remainder was given palliative treatment 
by repeated injections for the reason that 
surgery was either impractical or refused. 
Fifty per cent of the patients operated upon 
for recurrence had operations done within 
three years after injections were begun. The 
high percentage of recurrence within three 
years would lead to the conclusion that some 

American Journal oj Surgery' 



patients were improperly selected for injection 
treatment. 

Table ii shows the trend over a period of ten 
years. The number of patients treated by 
injection rose to a peak in 1943 to 1944 and 
then declined. The recurrence rate continued 


Table i 


No. 

Patients 
Discharged 
As Cured 

Symp- 

tom- 

free 

(yr.) 

1 

Recurrences 

Recurrences 

Operated 

No. of 
Cases 

Symp- 

tom- 

free 

(yr.) 

No. of 
Cases 

Years 

after 

Injec- 

tion 

Treat- 

ment 

i 

159 

3 

129* 

3 

33 t 

3 

167 

5 

34 

5 

7 

4 

172 

8 

10 

8 

12 

5 

I 16 

8 

2 

8 

12 

8 

614 


'75 , 


64 



36.5% of all patients with recurrences were operated 
upon; balance continued injection. 

* 74% of all recurrences occurred within three years. 

t 50% of operated recurrences operated before three 
years following injection. 

to rise with the number of hemorrhoidectomies 
keeping pace reaching a peak in 1947. This, 
doubtless, is due to the accumulation of recur- 
rences from previous years. 

SUMMARY 

To follow up accurately even a small series 
of cases is most difficult and many times 
impossible. After relief of symptoms the patient 
is prone to disappear. Following the recurrence 
of symptoms he may go elsewhere for treat- 
ment. The recurrence rate is too high to consider 
injection with 5 per cent phenol-in-oil, the 
treatment of choice. As a palliative procedure 
it is excellent and justifiable. In third degree 
hemorrhoids after repeated periods of treat- 
ment phenol-in-oil injections become of de- 
creasing value until they fail to be even 
palliative. 

CONCLUSION 

Injection therapy using. 5 per cent phenol- 
in-oil cures a fairly large proportion of patients 

Januan,^, ig^o 


with simple, first degree hemorrhoids and gives 
a varying degree of relief to those having 
second and third degree piles. But in no 
instance is the result better than that which 
can be obtained by careful surgical excision. A 
patient is discharged as cured following hemor- 


Table ii 


Year 

No. of 
Patients 
Injected 

No. of 
Patients 
Dis- 
charged 
as 

Cured 

No. of 
Patients 
with 
Recur- 
rence 

after 

Injection 

No. of 
Patients 
with Un- 
compli- 
cated 
Hemor- 
rhoids 
Operated 
upon and 
Not 

Injected 

No. of 
Hemor- 
rhoid- 
ectomies 
in Recur- 
ring 
Cases 

No. of 
Cases 
Discon- 
tinued 
Injection 
Treat- 
ment 
Before 
Dis- 
cha rge 

1938 

44 

33 

1 


2 

1 1 

1939 

49 

37 

2 


3 

1 2 

1940 

6$ 

50 

3 

18 

2 

*5 

1941 

98 

74 

2 

20 

I 

24 

1942 

80 

63 

6 

27 

3 

17 

1943 

108 

84 

8 

32 

5 

24 

1944 

1x7 

98 

24 

28 

9 

XQ 

194 $ 

88 

68 

30 

51 

7 

20 

1946 

71 

57 

35 

X 10 

4 

14 

1947 

64 

50 

64 

129 

28 

14 

Total 

784 

(65.4%) 

614 

175 

4x5 

(34.6'rc) 

64 

ITO 


rhoidectomy with a definitely greater assurance 
that recurrence will not occur than is possible 
after the injection therapy. 

REFERENCES 

1. Bacon, H. E. and Wolf, F. D. The injection treat- 

ment of hemorrhoids. Illinois M. J., 81: 202, 

1942. 

2. Corbett, J. J. Office treatment of hemorrhoids. 

Am. J. SuTg., 50: 641, 1940. 

3. Gabriel, W. B. Treatment of hemorrhoids. Bril. 

M. J., 2: 1266, 1939. 

4. Haskell, Benj. Office tre.atment of hemorrhoids 

etc. M. Clin. North America, 23: 1683, 1939. 

5. Kilbourne, N. j. Internal Hemorrhoids: 

Comparative value of treatment by operation 
and injection methods. Ann. Surg., 99: 600, 1934 

6 . Oden, C. L. A. An improved needle for injection of 

internal hemorrhoids. J. Michigan M. Soc., 39: 
104, 1940. 

7. Rosser, C. and Wallace, S. A. Tumor formation: 

pathological changes consequent to injection of 
oils under rectal mucosa. J. A. M. A., 99: 2167, 
1932. 

8. Whitnev, E. T. and Gasper, A. Progress in man- 

agement of hemorrhoids. Am. J. Surg., 63: 296, 

1943. 

9. Yaker, D. N. Hemorrhoids — surgical vs injection 

treatment. Am. J. Surg., 65: 88, 1944. 
n>. Yeo.mans, F. C. Office treatment of hemofrlioids. 
A'/. Clin. North America, 26: 831, 1942. 



52 


Pfeifer — Phenol-in-oil as Injection Treatment 


DISCUSSION OF PAPERS BY DRS. GASS AND ADAMS, 
TERRELL, AND PFEIFER 

David Miller (Los Angeles, Calif.): The paper 
by Doctors Gass and Adams is one that certainly 
shows considerable thought and observation. I 
believe we all agree with the authors concerning 
what part of the intestinal tract constitutes the 
rectum, that the terminal opening is designated 
as the anal aperture or orifice and that the door 
of the abdomen is partly made up of the levator 
muscles, anal sphincters, fascia and skin. However, 
1 prefer to continue designating the terminal 3 cm. 
of the bowel as the anal canal. When wc speak of 
the colon we understand the term colon to mean a 
passageway made up of layers of tissue in the form 
of a tube surrounding a central lumen. When 
speaking of a tumor or ulcer of the colon wc under- 
stand that lesion is in the tissue surrounding the 
lumen. Similarly, in using the term anal canal wc 
mean the passageway leading from the rectum 
distally; that passageway is also made up of layers 
of tissue in the form of a tube surrounding a central 
lumen. Lesions of the anal canal are also under- 
stood to be located in the tissues surrounding the 
lumen of the canal. 

The authors in their paper propose that “hemor- 
rhoids are not varicosities but a herniation of the 
anal and rectal lining through a weakened musculo- 
fascial anorectal opening.” Wc use terms or names 
to distinguish one thing from another. A hemor- 
rhoid is thought of as a collection of varicose veins 
occurring beneath the mucous membrane or skin 
depending upon whether it is internal or external; 
and redundant mucosa or redundant perianal skin 
as more than necessary of that respective tissue. 
These terms imply just what structures wc are 
dealing with and their location. When dealing with 
tissue that protrudes through the anal aperture 
1 prefer to call it protruding internal hemorrhoids 
if it consists of collections of varicose veins covered 
with mucous membrane and protruding rectal 
mucosa if it consists only of redundant mucosa. I 
am not convinced that a weakened musculofascial 
anorectal opening is the cause of an increase in the 
amount of this tissue. I agree with the authors that 
there are patients who have atonic sphincter 
mechanisms which occurred as a result of some 
accidental injury to the sphincter mechanism or 
following some operative procedure and who have 
a mild protrusion of mucosa or of internal hemor- 
rhoids. Such protrusions in these patients can be 
considered as occurring as a result of the atonic 
sphincter mechanism. The surgical correction of 
the anal sphincters in these cases occasionally is all 
that is necessary. Similarly, a protrusion of the 
rectum can often be cured by correction of the 
weakened musculofascial supportive tissue around 
the opening in the perineum as demonstrated by 
the Barrett operation in The American Journal of 
Surgery, March, 1943. But these patients with 


atonic sphincter mechanisms did not comprise the 
majority of the patients in my experience who 
complained of protruding hemorrhoids. 1 can recall 
a number of patients whom 1 have examined who 
had atonic anal sphincters not due to trauma or 
surgery and who had no complaints relative to 
hemorrhoids and in whom protruding hemorrhoids 
or mucosa was not found. The majority of the 
patients that 1 have treated for hemorrhoids had 
in addition some degree of stenosis of the orifice 
cither due to sphincter spasm or scar-tissue con- 
traction. The presence of hemorrhoids in these 
cases is contrary to the theory advocated in the 
paper under discussion. Surgical removal of the 
hemorrhoids and correction of the spasm or con- 
tracture cured the patients of their complaints and 
there was no recurrence of the hemorrhoids in 
later years. 

From my observations with the treatment of 
hemorrhoids I have come to tlic following con- 
clusion: Hemorrhoids per sc is not a disease but a 
complication of one or more conditions and the 
method of treatment and prevention of recurrence 
of hemorrhoids depends upon what that condition 
is. 

C. E. Heuaud (Tampa, Fla.): I would like to 
take this opportunity to congratulate the authors 
on their fine presentation of the material they have 
collected and the observations they have made. 
While 1 do not agree with all of their findings, 1 
believe that the differences of opinion arc largely a 
matter of terminology and definition. 

Dr. Harry Bacon in his latest book describes 
proplapsc of the anorectal area as “the abnormal 
descent of the mucous membrane of the rectum 
with or without protrusion through the anal 
orifice.” He defines procidentia as “the abnormal 
descent of all the coats of the rectum with or with- 
out protrusion through the anal orifice” while the 
authors describe these same conditions as hernia- 
tion of the rectal lining. Do the authors simply 
wish to change the names of the abnormalities 
described and refer to these conditions as hemor- 
rhoids? When the authors speak of a herniation 
of the rectal lining through the musculofascial 
anorectal opening with or without the involvement 
of the submucosal plexus of vessels, they are, in 
my opinion, describing a minor prolapse or proci- 
dentia but not hemorrhoids. I prefer to consider 
hemorrhoids as our old friend Hippocrates so aptly 
describes them, as a vascular tumor of the rectal 
mucous membrane. 

We agree that hemorrhoids are produced in 
various ways from stress placed upon the loose 
connective tissue stroma with its interwoven 
hemorrhoidal plexus. This may be due to straining 
at stool, long sitting, standing, riding, lifting or 
from many other causes which arc to numerous to 
mention. It has been my observation that loose 
stools, particularly those produced by mineral oil, 

American Journal of Surgery 



Pfeifer — Phenol-in-oil as Injection Treatment 


53 


may be a factor in the production of hemorrhoids. 
I am also in agreement with the authors on their 
second observation, that hemorrhoids arc fre- 
quently found in individuals with other signs of 
weakened supportive or connective tissue. And I 
also believe that heredity and environment play a 
large part in the production of hemorrhoids. 
I do not agree with the authors in their fourth 
observation, that all forms of treatment and all 
operations for hemorrhoids should be designed and 
executed for the prevention of herniation of the 
rectal and anal wall and not for the obliteration of 
veins as in the case of varicosities of the extremities. 
1 consider the object of anorectal surgery to be the 
removal of all pathologic conditions in order to 
obtain the best possible functioning anus and 
sphincter. Most proctologists have much the same 
objective although the approach and procedure 
maj"^ be varied. In my work I have also found the 
Pansier operative anoscope a most useful in- 
strument. I strongly recommend postoperative 
education of the patient to obtain the best possible 
results. 

Pathologic reports from my own cases are not in 
agreement with those reported by the authors but 
are similar to those reported by Ball, Boyd and 
Moore. This difference in pathologic changes may 
be due to the selection by the authors of patients 
who had large protruding masses of internal 
hemorrhoids. 

I believe that the observations presented should 
provoke considerable discussion. 

L. E. Brown (Berkeley, Calif.): It is a huge task 
to check through one’s records to secure accurate 
information on patients treated five to ten years 
ago as well as to follow through with questionnaires 
and to obtain data on the present condition of 
patients. It is well from time to time to reflect on 
our work and the results of our treatment. Because 
of the work of these essayists and the study given 
by them these papers allow proper evaluation of the 
injection treatment of hemorrhoids. The authors 
arc to be complimented for their work in presenting 
this information to us. 

In general the papers essentially are in agree- 
ment and also bear out my teaching and e.xperience. 
The injection treatment of internal hemorrhoids 
has merit in the hands of those who use it correctly 
and who exercise good judgment in the selection of 
cases for its use. We occasionally see' patients who 
have had injection treatment for external hemor- 
rhoids. This is’jto be strongly) condemned since it is 
ineffective for treatment',' causes much ,pain to the 
patient, invites complications and is a' discredit to 
the physician and the' injection treatment. 

Certainly in uneomplieated internal hemorrhoids 
this treatment has withstood the test of time and 
has successfully alleviated- the patient of his 
symptoms or has effected a. cure. In internal pro- 
lapsing hemorrhoids of moderate degree the 

Januaiy,- igjO " 


judicious use of injections will often result in a 
satisfied patient and usually a delightfully surprised 
physician. 

In complications of anorectal infection such 
as ulcer, fistula-in-ano, external thrombotic hem- 
orrhoids and definite cryptitis and papillitis, 
injections of internal hemorrhoids is certainly 
contraindicated except, perhaps, as a very tem- 
porary emergency measure to control bleeding 
until correct surgical treatment can be undertaken. 
I have observed patients with an early but definite 
cryptitis in whom hemorrhoids, both internal and 
external, developed within a few months. It is 
difficult to believe that the injection of these 
internal hemorrhoids will control the anal infection 
which apparently preceded the formation of the 
hemorrhoid. During the last few years more atten- 
tion has been given to cryptitis as the cause of 
hemorrhoids. The injection treatment of apparently 
simple internal hemorrhoids which have this asso- 
ciated condition usually will not result in perma- 
nent cure. I believe this cryptitis is the cause of 
most of those recurrences which finally come to 
operation. 

The percentage of cases suitable for injection 
varies with the type of practice as the general 
practitioner will see these patients earlier and with 
fewer complications than those referred to the 
proctologist. Also, physicians who have and deserve 
the reputation for successfully giving this type of 
treatment will see more of these earlier, simple 
cases suitable for injection. Dr. Pfeifer refers to 
Dr. Yeomans’ satisfactory results in 8o per cent of 
his cases — I presume this is in the cases of internal 
hemorrhoids suitable for injection. Dr. Pfeifer 
selected 65.4 per cent of patients for injection, with 
a recurrence of 21 per cent and, as he states, some 
were injected which were known to have been 
surgical cases. Dr. Terrell found that 25 per cent of 
his patients who have hemorrhoids were suitable 
for injection; because of his careful selection his 
recurrence rate is very low. In those patients who 
are to receive injection for internal hemorrhoids 
the proctologist will do well to explain the antici- 
pated results; whether permanent cure or tem- 
porary and palliative results are expected. This is 
especially desirable in patients who may have 
injections as second choice to surgery, namely, 
those patients who for economic or general health 
reasons are unable to have surgery or those who 
flatly refuse it. Many of these will be greatly 
benefited by injections and will be perfectly satis- 
fied patients but they should be under no false 
illusions as to the expected results. However, if 
their disease is controlled, if they are asj^mptomatic 
and if they are satisfied with the results, they 
should not be denied this form of treatment. 
Perhaps if we do not give it to them, thej' will go 
elsewhere and be treated by those less competent. 

The successful treatment of hemorrhoids requires 



54 


Pfeifer — Phenol-in-oil as Injection Treatment 


the same care as the successful treatment of any 
disease, namely, a careful history, an adequate 
examination, good judgment in proper selection 
of cases, an understanding patient and the proper 
technic of injection. 

The papers under discussion have nicely reviewed 
this problem and have foeused our attention on 
important points. 

Edward T. Whitney (Boston, Mass.): The 
papers of both Doctors Terrell and Pfeifer have 
demonstrated the need for adequate selection of 
patients to whom injections should be given. The 
age old controversy of whether to inject or operate 
will ])robably always be with us. However, there 
really should be no such controversy. Anyone 
trained in or at present running a large outpatient 
rectal clinic just does not have the time, strength 
nor desire to operate upon every little hemorrhoid 
that he encounters. Our statistics at the Boston 
Dispensary based on 4,156 new clinic admissions 
reveal that 60 per cent of our patients have hemor- 
rhoids. From a practical standpoint operation on 
all of these patients is impossible. The answer to 
the problem long ago resolved itself into operating 
on all combined external-internal hemorrhoids and 
injecting all simple, uncomplicated internals. In 
other words, only those patients should be selected 
for injections who, experience has shown, are 
amenable to injection. When we say amenable to 
injection we mean that the existing hemorrhoids 
can be obliterated thereby and will remain obliter- 
ated for a reasonable length of time. Our figures 
indicate that under ideal circumstances 47 per cent 
of our patients with hemorrhoids can be injected. 
But the ideal does not exist in such a clinic as ours 
and we are forced to inject many of those with 
combined externals or those with complications if 
relief is at all possible even though recurrence is 
frequent. The necessity for repeated injections 
every few years is no valid objection — it is still 
better than nothing. It docs stop bleeding and 
prolapsing and it does slow down further develop- 
ment of the condition. 

However, for successful results whether under 
ideal circumstances or not it is necessary to know 
the limitalions of the sclerosing process itself and 
apply ingenuity and system in an effort to over- 
come them. Both Doctors Terrell and Pfeifer have 
admirably applied such qualities to the problem. 
We would like to add a few similar observations: 

First, we have found that much better results 
can be had if the type of sclerosing solution is 
varied according to the particular need presented 
by the individual hemorrhoid or the patient at the 
time of individual treatment. For instance, in the 
beginning large hemorrhoids call for large amounts 
of solution, preferably phenol-in-oil; but after some 
contraction has taken place, smaller doses of 
quinine are indicated. The synergistic action of the 
combination of both is thereby taken advantage of. 


On the other hand, too severe a local reaction some- 
times accompanies one of these solutions in which 
case the other should be substituted. 

Second, in addition to injecting the upper and 
lower poles it is necessary in many cases to inject 
deeply beneath the previously produced indurations 
as the latter may have created only floppy balls of 
fibrosis just under the redundant mucous mem- 
brane. Deep injection beneath these floppy struc- 
tures attaches them firmly onto the muscle wall 
and brings about further contraction and flattening. 
To attain such a deep injection it is usually neces- 
sary to go into the side of the hemorrhoid and feel 
one’s way along beneath the indurations or fibrosis. 

Third, one should not let up on the injections 
until a flat mucous membrane is obtained. This 
requires waiting periods of varying lengths of time 
in order to allow major contraction from prior 
injections to take place. After a series of injections 
has been given, the patient needs to be seen again 
in three months and again after six months and all 
residual redundancies obliterated. Often on these 
occasions some very small but active hemorrhoids 
will be found present right on the mucocutaneous 
line representing some low varicosities not sclerosed 
by the previous injections. These require yi cc. or 
so of quinine even though pain is produced by the 
introduction of the needle or the solution. 

Fourth, the possibility of severe general reactions 
and the occurrence of sloughs should be taken into 
account. Our records, both private and clinic, in- 
volving more than 8,000 new cases reveal the 
incidence of four severe general reactions, all 
requiring adrenalin, antihistaminics and opiates. 
All four reactions followed the administration of 
quinine. 

Sloughs probably occur more often than we 
suspect but recognized ones in this series averaged 
.5 per cent. Again more of those followed quinine 
than phenol-in-oil. However, these mishaps are no 
more frequent nor more serious than those which 
occur in the use of any medication given parentally 
and should be taken in stride. 

We were particularly intrigued with both Doctors 
Terrell and Pfeifer’s advocacy of a method whereby 
they divide the usual dose between three or four 
hemorrhoids at one sitting. However, the novice 
should watch himself very, very carefully in follow- 
ing such a practice in order that he does not give 
loo much too soon in any one place. For the present 
we would advise him to stick to the older technic 
of injecting one hemorrhoid at a time and waiting 
at least three weeks before repeating treatment in 
that same location and, further, to keep in mind 
always that only some 40 to 50 per cent of his 
patients are ideally amenable to injection. Injection 
of the others without all parties knowing the 
extenuating circumstances discredits the procedure, 
mars the reputation of the operator and lowers the 
standing of the proctologic profession. 

American Journal oj Surgery 



Pfeifer — Phenol-in-oil as Injection Treatment 


53 


Harold Dodd (London, England): With regard 
to the etiology of hemorrhoids, I have found a 
remark made by Mr. Campbell Milligan of St. 
Mark’s Hospital extremely useful. He said that 
the basic etiology of hemorrhoids is that people 
with them are born with too many veins in the 
lower end of the rectum and the anal canal and 
that these veins are of poor quality. A certain 
amount of substance is lent to this statement by the 
fact that varicose veins in the leg and anal canal 
often go together and that these two conditions are 
frequently hereditary. 

In addition, of course, the hemorrhoids are 
aggravated by a series of conditions that all begin 
with C; but these do not necessarily cause hemor- 
rhoids. The C’s are as follows: C for chest condi- 
tions or chronic cough: C for cardiac conditions; C 
for cirrhosis of the liver and chronic cholecystitis; 
C for constipation; C for colitis; C for cancer of the 
rectum; going forward a step, C for a child in the 
uterus; and going forward still a further step, C 
for clap. This reminds us that stricture of the 
urethra and chronic prostatitis have an aggravating 
effect on conditions at the lower end of the rectum. 

We classify hemorrhoids into three degrees: In 
the first stage the veins of the anal canal are in- 
creased in number and size; during the action of 
defecation they are traumatized and bleed. In the 
second stage the internal and external hemor- 
rhoidal veins are enlarged and the longitudinal 
muscle of the rectum is somewhat stretched in 
contrast to the normal in the first degree. This 
type of hemorrhoid both bleeds and presents during 
defecation, but afterward returns spontaneously 
without any assistance from the patient. We find 
that in the first degree 95 per cent are relieved for 
long periods by injection and many of them are 
cured; about 65 per cent of hemorrhoids of the 
second degree are cured by injection. 

The third degree of hemorrhoid consists of a large 
mass of both internal and external hemorrhoidal 
veins which is entirely outside the anal canal; the 
fact is that the external sphincter keeps the mass 
outside. Frequently it no longer bleeds because 
it has been traumatized and its covering is tough. 
That type of hemorrhoid comes down when pa- 
tients are tired or when they are lifting or walking. 
We believe that third degree hemorrhoids must be 
removed. The three degrees of hemorrhoids are 
useful for a pathologic classification and it assists 
us in our selection of patients for injection or for 
operation. 

Claude C. Tucker (Wichita, Kan.): You speak 
of the injection treatment for internal hemorrhoids, 
injection treatment being considered only for cases 
of internal hemorrhoids. If you section the hemor- 
rhoid for microscopic examination, you will find 
that 98 per cent of the patients have external 
hemorrhoids as well. 

Internal and external hemorrhoids have their 
Januanr, iq$o 


origin in anal ducts. Injection in these ducts set up 
an inflammatory condition in the surrounding 
tissues thus causing a conglomeration of connective 
tissue and blood vessel walls similar to varicosity 
of the other parts of the body. 

In injecting a sclerosing solution you block the 
drainage from these ducts, therefore not relieving 
such symptoms as backache, pain in extremities, 
extreme nervousness and that tired, worn-out 
feeling day and night. 

E. D. Parkinson (Boise, Ida.): First, I believe 
that in order to cure hemorrhoids they must be 
removed. 1 answered Dr. Terrell’s interrogation 
when he wrote to us asking if we thought we could 
cure hemorrhoids by injection with the statement, 
yes, if a slough is produced. By accidentally pro- 
ducing sloughs a few times and watching the results, 
I found out that those people really did get a cure. 
That really amounts to surgical cure. Of course, the 
type of hemorrhoid that we inject must follow all 
of the rules that we should always adhere to. 

I use larger doses of injection material than 
formerly which probably accounts for the rather 
frequent occurrence of sloughs. It has been sur- 
prising that no other complications in addition to 
the sloughs have occurred but that the results 
obtained have been better in those cases than 
otherwise. 

O. C. Gass (Chattanooga, Tenn.): I certainly 
enjoyed the discussion; it was very instruetive. One 
of the questions suggested was: Do we wish to 
change the terminology of hemorrhoids? No. What 
we wish to do is eall attention to the fact that the 
initial disease in the formation of hemorrhoids is 
in the connective tissue stroma and not in the blood 
vessels. 

Someone asked if the pathologic findings could 
be due to the selection of the specimens. The 
illustrations shown were truly representative of 
the findings of the entire group. It was brought up 
in the discussion that we recommended for all 
operations to be designed to remove loose tissue 
rather than varicose veins. 

In my surgery I pay no attention whatsoever to 
veins. I know that if I remove the loosened, 
herniating mucosa and the redundant perianal 
tissue, the veins will take care of themselves. 

Regarding the question of hemorrhoids being 
produced by straining from strictures and things 
of that kind, certainly a stricture will result in an 
inguinal hernia just as quickly as it will dilation of 
varicose veins and certainly should increase 
herniation of the rectal mucosa. 

When I suggested this study to our pathologist. 
Dr. Adams, he was rather reluctant to participate. 
However, he studied the pathologic textbooks and 
found very little on the subject. He has become 
quite enthusiastic; he thinks we are going into 
connective tissue rather than vein-tissue_pathologj' 



56 


Pfeifer — Phenol-ln-.oil as Injection Treatment 


and he is planning to make a report of our findings 
to the Pathologic Society. 

Robert V. Terrell (closing): In the main I 
thought the discussers emphasized points that 
perhaps we should have emphasized a little bit 
more in our talks and I think they have been most 
worth while. I want to thank everyone for taking 
the time to fill out the annoying questionnaire. 

I have been asked privately whether or not I 
inject pregnant women. I think a word might be 
said on that. I certainly do. I prefer to, do the 
injection in the second trimeter of pregnancy but 
will do it at any time when the symptoms are 
sufficiently annoying to need correction. 1 try 
particularly to continue the treatments and get 
the patients in the best possible rectal condition 
for the ordeal of delivery. 

Dr. Tucker is very right in that internal and 
external hemorrhoids do occur together much more 
frequently than is commonly supposed. Very often 
I think unless we have our patients strain down in 
the course of an examination we may overlook the 
external hemorrhoids that are present. 

In regard to whether or not we can cure backache 


by injections, I think perhaps we help that, too, 
sometimes. I am not making such claims. 

In regard to Dr. Parkinson’s intentional slough, 
I will concede that sloughing gets rid of hemor- 
rhoids, 1 could not recommend it to you. 1 think 
that perhaps he states a convincing truth and 1 
accept his opinion. Unless you have a wide experi- 
ence with the method and know very much what 
you are doing, I should most urgentlj’- emphasize 
that at all costs undertreat rather than overtreat 
your patient insofar as production of a slough is 
concerned. 

It was I, Judge Morgan, who reduced internal 
prolapsing hemorrhoids and injected them, I do not 
wish to be in contempt of court but I have done 
this many times by injecting a little higher than 
usual, applying a binder and I have so far been 
unapprehended. 

A. C. Pfeifer (closing): It looks as though 1 am 
going to have the last word. I have a whole page 
of notes that 1 have taken. I am going to do a very 
unprecedented thing. 1 am going to thank the 
discussers and everyone for their interest and for 
the reception of our papers and wind this thing up. 
Thank you. 




■X. 


American Journal oj Surgery 



PROCTOCYSTECTOMY 

. THE MANAGEMENT OF COLOSTOMY WITH URETERAL TRANSPLANTS 

Lyon H. Appleby, m.d., f.r.c.s. (Eng.), f.r.c.s. (Can.) 

Vancouver, British Columbia 


A T the point of divergence of the deferent 
duct and between them, to a varying 
degree, the rectum and bladder are in 
contact. This area is small with an empty 
bladder but increases with bladder distention. 
It used to be a common practice to puncture 
the bladder through this region to relieve re- 
tention of urine. The part of the bladder in 
contact at this point is the posterior part of the 
trigone. Carcinomas involving this area or fixed 
to bladder, prostate or seminal vesicles have 
been amenable only to palliation; the incidence 
of local recurrence has been high and the per- 
centage of so-called five-year cures negligible. 

In order to justify expansion of the scope of 
rectal resection one must be in reasonable agree- 
ment with respect to the intrinsic nature of 
carcinoma of the rectum. This condition is, in 
comparison with gastric or vesical carcinoma, 
frequently of low grade malignancy, slow 
growth, late extension and frequently superven- 
ing upon benign lesions. For a long time it may 
be locally invasive before becoming widely dis- 
seminated. I believe we can also agree that re- 
mote postoperative recurrence is an “act of 
God” whereas such local recurrence is evidence 
of incomplete or inadequate surgery. 

The cases forming the basis of this report are 
contained in Table i: 

Table i 


Abdominoperineal resections 304 

One-stage resections 236 

Operative mortality rate 

(last 1 00 consecutive cases) 4% 

Five-year survival 47-7% 

Anterior wall in the male 

(locally invasive cases) 19 


I have performed many one-stage abdomino- 
perineal resections in which that was possible. 
From Table i I wish to consider the nineteen 
cases situated on the anterior wall in the male, 
invading or densely fixed to bladder, prostate 
or seminal vesicles without remote metastases 
or distant nodes and nothing to make one 
believe that the lesion was other than a locally 
invasive process. There were no radiographic, 

January, jg^o 


clinical or hematologic presumptive evidence of 
serious physical depletion or spread. 


Table n 

Anterior w.ill inv.ading bladder 19 

Treated by abdominoperineal reseetion 13 

Proetocystectomy. 6 


The growths in the thirteen patients treated 
by abdominoperineal resection were removed 
as completely as possible; but in many in- 
stances the growth was obviously not all 
removed. Prostatic capsules, deferent ducts, 
lower ureters or seminal vesicles were being 
invaded. In several instances the carcinomatous 
ulcer was opened during separation from these 
struetures. 

Refuge was taken in radiation and hormonal 
inhibitional therapy but every one of them had 
eventually extensive loeal reeurrence with 
miserably invasive growths, fistulous abseesses, 
strangury, prolonged agony and steneh. If one 
regards this as palliation, the jest is grim 
indeed. The fistulous, foul, painful and post- 
radiation sequelae were not easily forgotten 
and made me wonder whether these patients 
w'ould not have been better off if left alone 
altogether. I consequently decided that in the 
future I would either do nothing or attempt 
something much more radical in these cases. 
Something more than a blind response to pre- 
vailing tradition is required; the patient should 
no longer be subjected to standard operations 
but the operation should be fitted to their 
unusual needs. 

The current trend of the treatment of car- 
cinoma is toward Gargantuan efforts of 
extirpative surgery. In my opinion this is a 
natural corollary to the development of modern 
preoperative eoncepts of preparation, the in- 
creasing availability of blood and plasma banks 
and other measures of controlled support, 
together with the splendid advances of modern 
anesthesia. 

However, when one survej’^s the fields to 
which efforts have been applied, namely, 
massive organismal resections of posterior 


57 ■ 



58 


Appleby — Proctocystectomy 



Fig. I. Right ureter transplanted to anterior surface 
of cecum; brought through a hole in the mesentery 
just above ileocecal junction; autopsy table photo- 
graph. 

carcinoma of the fundal stomach, e.\tensive 
transthoracic esophageal resections and com- 
plete pelvic eviscerations for carcinoma of the 
cervix; one cannot help but believe that in the 
rectum, with its more favorable pathologic 
cellular basis courage in the extension of 
extirpative effort must carry vast and sub- 
stantial rewards. 

Let us compare ordinary resections affecting 
stomach and rectum. The following facts do 
not need to be tinctured with personal opinion: 

Table hi 

OPERATIVE MORTALITIES 


Gastric resection for ulcer 

Cases 533 

Operative mortality 2.1% 

Gastric resection for cancer 

Cases 294 

Operative mortality 13.9% 

Abdominoperineal e.xcision 

Cases 304 

Operative mortalitj' 6.2% 


These operative mortality figures are spread 
down through twenty years and would look 
better if the last five years’ cases only were 
presented. 

Table iv 

FIVE-YEAR survivals 



294 

3% 


8 

304 

47.7% 


146 j 


While the operative mortality of abdomino- 
perineal resection does not in my hands 


approach the results for instance of gastric 
resection for non-malignant lesions, it is less 
than half the rate for gastric resections for 
carcinoma. Furthermore, in consideration of 
the survival rates the two bear no possible 
comparison. This is presented in justification 
of the need for expansion of scope in certain 
cases of abdominoperineal resection for cancer. 

The purely plij'^sical problem of removal of 
the rectum, bladder, prostate, vesicles and 
levators is not one requiring much discussion 
here. However, the problem of how best to 
transplant the ureters and care for the colos- 
tomy in the presence of ureteral transplants is 
definitely intriguing. The average colostomy 
with which we are familiar is perfectly com- 
fortable on dietary instruction, two-daj" irriga- 
tion control and a small pad, and has in recent 
years supplanted almost entirely the vast 
array of gadgets, pouches and bags. However, 
the increased lluiditj' of bowel contents in the 
presence of ureteral transplants renders colos- 
tomy care somewhat of a trial. 

In England, 1921, a child was born to a 
young doctor’s familj^ with an extrophy of 
bladder and an absent or non-functioning left 
kidney. I transplanted the right ureter with a 
button of bladder mucosa into the cecum. The 
child was a year old when operated upon; lived, 
grew up and died a traumatic death in 194.3. 
For me this established the fact that right- 
sided transplants were not, as has been stated, 
incompatible with life. 

Since then I have transplanted the ureters in 
thirtj’^-one patients; in twentj’’-two of them the 
right ureter was transplanted into the cecum 
and the left ureter into the sigmoid. All but 
five of these twentj'-two were transplanted 
because of far advanced pelvic carcinoma 
originating in bladder, cervLx or rectum. All 
died in the normal course. In seven of these 
at autopsy there was no greater degree of right 
renal involvement than there was on the left 
side. Of the five transplanted for reasons other 
than malignancy one has vanished, one died of 
bilateral suppurative nephrosis and three have 
survived eleven, seven and five years, respec- 
tively, and when last reported were in good 
health. (Figs, i and 2.) 

I have now to report on six patients in whom 
I have resected rectum, bladder, prostate and 
vesicles in one block for invasive anterior wall 
carcinoma of the rectum without evidence of 
other than purely regional spread. In the first 
three cases one ureter was transplanted to the 

American Journal of Surgery 



Appleby — Proctocystectom y 


cecum and one to the sigmoid. In the last three 
both ureters were transplanted into the cecum. 
I am convinced that in these days of modern 
physiologic concepts of preoperative care the 
availability of blood banks, plasma and anti- 
biotics, that this whole operation should be 
accomplished in one stage. The edema incident 
to reopening for a second stage far outdoes 
the added risk, if any, of primary complete 
dispositions. 

Regarding the technical procedure of the 
operation exposure is nearly everything. I use 
an anchor-shaped incision with the vertical 
limb over the inner side of the left lower rectus 
to the umbilicus, with two lateral limbs from 
the lower end transecting the whole abdominal 
wall including the lower end of each rectus 
abdominis muscle. This lays the abdomen wide 
open and once the ureters are transplanted, the 
actual removal of the pelvic contents is less 
difficult than an ordinary abdominoperineal 
resection. 

I place a primary ligature around both 
internal iliac arteries just below the gluteal 
origin; when ligated, the pelvic removal be- 
comes relatively avascular. One can then slide 
around the walls leaving nothing but bones 
and there is nothing for which one need watch 
except perhaps the spermatic vessels; the 
spermatic cord is severed and turned down 
at the internal inguinal ring.. The ease with 
which a new floor may be created is directly 
proportional to the care with which the perito- 
neal flaps are prepared when the operation 
commences. Closure of the abdomen is best 
accomplished with through-and-through steel 
wire for all layers except skin. The colostomy 
consists of a straight loop type without frills 
through the upper end of the vertical limb. 

My object in using the cecum as a site for 
ureteral transplants was in- the hope that the 
large bowel would absorb sufficient watery 
element of the urine to render the colostomy 
less of a trial. The major substances which are 
absorbed through the large bowel are water, 
glucose, sodium chloride and alcohol. Careful 
check of the efflux of these cases has revealed 
that the colostomy efflux is reduced by about 
30 per cent so that it has helped considerably. 
For years I have jettisoned the various gadgets 
in use for the control of colostomy depending on 
irrigation control and diet but in these cases, 
regardless of whether the transplants be into 
cecum, sigmoid or one ureter into each, there 
is no colostomy with which I am familiar which 

January, ig$o 



Fig. 2. Left ureter brought under mesentery of the 
sigmoid; transplanted to under surface of the mobi- 
lized cecum; tip of appendix indicated in forceps; 
autopsy table photograph. 

does not require some form of plug control to 
prevent a “wet” colostomy. I have found 
nothing more satisfactory than the ordinary 
Foley bag type of catheter. The projecting part 
is long enough to be handled through the 
trousers without undressing and the bulb can 
be dilated to individual necessity. 

In an ordinary colostomy it has been my 
custom to leave it clamped off for a few days 
to prevent the wound from soiling but in these 
cases a large bulbous retention catheter should 
be tied into the projecting bowel. Otherwise, a 
large amount of urine will collect and cause 
discomfort. 

An interesting study has been made of the 
blood non-protein nitrogen in these right-sided 
transplants as compared to those in whom 
transplants have been made without colostom}'. 
In those cases with cecal transplants the aver- 
age reading of 19 estimations per case was 48 
mg. per cent, while in sigmoidal transplants 
without colostomy, the average reading of 
17 estimations per case was 34 mg. per cent. 

In order to check the absorptive power of the 
large bowel with respect to urinary products a 
patient in the hospital was given through her 
cecostomy into her colon 6 Gm. of urea, and 
hourly blood and urine urea estimations were 
made. It is obvious from a glance at Table v 
that in four hours the absorption of urea from 
the large bowel is negligible. This test was sug- 
gested to me in personal conversation with 
Thorlaakson of Winnipeg. 



6o 


Appleby — Proctocystectomy 


Table v 

UREA AND N.P.N. ESTIMATIONS 


llour 

N.P.N. 

(mg. %) 

Blood 
Urea N. 
(mg. %) 

Urine 
Urea N. 
(mg. %) 

9:00 

24 

8.8 

323 

10:00 

26 

10 

333 

1 1 ;oo 

27 

10 

384 

1 2:00 

28 

i 

9-5 

no s])cc. 


The outcome of these six cases of procto- 
eysteetomy has been interesting and is con- 
tained in the Table vi: 

Table vi 

Proctocystectomy 6 

Operative death i (i6.6%) 

Metastatic death i (lived 14 mo.) 

( 7 yr- 

Ifiyr. 

yr- 


The survivors represent my first four cases. 
The last two patients have died : one an opera- 
tive death, the other fourteen months later 
from metastases. No pre- or postoperative 
radiation had been used in tliese cases. No case 
done less than two years has been included in 
this series. Such additional cases will be the 
basis of a subsequent report. 

SUMMARY 

The low grade, slow growth nature of cancer 
of the rectum justifies the most radical meas- 
ures directed toward its cure. 

Transfer of urine to the cecum is compatible 
with life over a period of at least twenty-two 
years. 

Transfer to the cecum has reduced the 
quantitative efflux of urine b\" about 30 per 
cent but insufficient to render the colostomy 
trustworthy. 

The present series is so small that it affords 
a basis only for conjecture, hope and further 
study. 




American Journal of Surgery 


HIDRADENITIS SUPPURATIVA INVOLVING THE 
PARAANAL REGION 

J. B. Christensen, m.d. 

Omaha, Nebraska 


T he purpose of this article is to call to the 
attention of the proctologist and those 
physicians treating diseases of the anal 
region a pyoderma infection involving the 
apocrine sweat gland of that region. 

The disease is frequently misdiagnosed as 
multiple anal fistulas, tuberculosis of the anal 
skin, granuloma and other inflammatory condi- 
tions. An understanding of the distribution, 
anatomy and function of the glands infected 
will lead to the proper diagnosis and treatment. 

I am presenting eight case reports of patients 
with hidradenitis suppurativa who came to us 
because they believed they had an anal fistula. 
(Table i.) 

HISTORY 

The first description of hidradenitis sup- 
purativa was made about one hundred years 
ago. Most early reports dealt with its occur- 
rence in the axillas and later involvement of 
the head, breasts and perineum. 

A very comprehensive thesis was written by 
Brunsting^ in ipsy in which he ruled out tuber- 
culosis as the cause of the condition. In 1939 
Smith- reported to the American Proctologic 
Society six cases of very extensive pyodermia 
about the anus in which he stated that one case 
was thought to be hidradenitis suppurativa. 
Jackman® published a paper in 1942 which 
dealt with this disease as found about the anus. 
Others have reported cases but among the 
general profession including the proctologists 
the disease is little known and, therefore, not 
often recognized. 

HISTOLOGY AND ORGANOLOGY OF THE APOCRINE 
GLAND 

There are two types of sweat glands. They 
are the apocrine glands and the common 
eccrine sweat glands. The3r are similar but 
differ definitely in manj”^ respects. While the 
eccrine glands secrete without rupture of the 
cell, the apocrine glands secrete partly in this 
manner and, also, partly" bj’- pinching off the 

January, ig^o 


outer portion of the cell which makes up much 
of the secretion coming from the gland. This 
secretion contributes to the problem of perspi- 
ration odor. While there are several million 
eccrine glands distributed over nearly the 
entire body surface, the apocrine type are 
estimated in the hundreds and are confined to 
the hair-bearing areas. For the most part 
apocrine glands are seen about the neck, 
axillas, undersurface of the breasts, pubic skin, 
vulvas and peri-anal skin. 

The apocrine glands have been called sex 
glands because they do not become active 
until puberty and gradually regress in the 
declining years. In women they are definitely 
more active in the day or two preceding 
menstruation. 

SYMPTOMS AND FINDINGS 

The first evidence of infection of the apocrine 
glands will be one or more firm, tender and 
injected nodules in the skin. Tenderness will 
continue and after two to six days a small 
amount of slightlj>- cloudj'’, oily fluid will begin 
to be discharged. This lesion may regress and 
very slowlj'^ return to near normal. Often the 
scar as it develops in the subcutaneous tissues 
tends to draw the skin into a stellate design 
in the center of which is an enlarged pore. The 
gland then may or may not be dormant for a 
long period of time. If the inflammatory process 
continues, the lesions become large and more 
tender. There is a distinct tendency’' for a direct 
subcutaneous spread or tunneling to develop 
in lines following the folds of the axillas or 
groin. The tunneling makes long ridges. A 
probe may be passed through the tunnel and 
out through the orifice of each involved gland. 
Many of the so-called blind, incomplete and 
external fistulas described in the past maj’’ have 
been this type of skin disease and in no waj’’ a 
true anal fistula. As the process continues it 
maj" involve all gland-bearing skin of the 
region. 

In the advanced, acute case the gland open- 
61 



62 


Christensen — Hidraclenitis Suppurativa 


ing may erode showing some of the rough, 
granular membrane forming the base of the 
tract. The overlying skin often becomes thin 
in areas and develops an atrophic glassy 
appearance. This involved skin may be darkly 
pigmented, deep red or a cyanotic color. 


gland as having something to do with the 
pathogenesis of the disease. The bacteria most 
frequentlj' found in the infected glands 
were Staphylococcus aureus and Streptococcus 
viridans. 

The discharge encountered in hidradenitis 


Table i 

CLINICAL DATA ON CASES OF HIDRADENITIS SUPPURATIVA 


No. 

Code 

Age 

Sex 

Duration 

(Yr.) 

Onset and Sites Involved 

Tre.atmcnt and Follow-up 

I 

M. N. 

25 

F 

7 

Axillas and perineum 

Excision of sinus in the pani-anal tissue 
still has dormant involved glands in the 
axillas 

2 

J.L. 

3° 

M 

2 

Para-anal 

Excision of scarred areas in the right 
lateral area; some openings healed, 
others active; typical discharge 

3 

0 . C. 

31 

F 

5 

Para-anal blind sinus 

Excised; no connection with the anus; 
several openings into the shallow sinus 

4 

R. B. 

40 

M 

10 

Very extensive para-anal both 
sides and into the groins 

Mad penicillin treatment with nO cure; 
three operations in one year appear to 
have cleared the infection 

5 

R. I. 

40 

M 

1 

Axillas and para-anal; drained 
repeatedly before entrance; very 
extensive both sides 

Excision of para-ana! sinuses followed by 
complete relief: very marked improve- 
ment of involved glands in the axillas 
without treatment 

6 

H. G. 

4' 

M 

'5 

Axillas and para-anal verj- exten- 
sive; much scarring in both 
groins; has acne 

Excision of para-anal sinuses’ complete 
relief; axillas now dormant 

7 

E. C. 

49 

M 

3 

Followed abscess of pilonidal 
cyst; developed sinuses: has 
acne 

Excision of involved tissue; later de- 
veloped infection of single glands on the 
scrotum; healed- after excised 

8 

L. C. 

56 

M 

12 

Had recurring sinuses on the neck 
and scrotum; later, para-anal 
and scrotum which continued to 
drain 

Excision of involved tissue of scrotum 
and para-anal skin: other areas dormant 


The single nodule or a sinus at the height of 
its involvement has a heavy fibrous membrane 
forming the base which consists of cords of 
connective tissue. These have granulation 
tissue above them and inflamed, fatty tissue 
beneath. The process does not involve deeper 
tissues because drainage is usually adequate. 

In one of our patients hidradenitis suppura- 
tiva began with the development of a pilonidal 
cyst, the discharge from which contaminated 
the peri-anal skin. Brunsting^ reported two 
cases in which the disease started in the axillas 
following an infection in the hand with sup- 
puration of lymph nodes in the axillas, suggest- 
ing that the pyogenic organism entered the 
orifice of the gland. In another of the patients 
herein reported isolated glands in the scrotum 
became involved when the skin was grossly 
contaminated with discharge, again suggesting 
direct entrance of bacteria into the duct of the 


suppurativa is moderate in amount, thin, 
cloudj' and has a musty odor while from an 
anal fistula the discharge often is copious, 
thick, grayish and usually has an odor of 
hydrogen sulfide. 

Extensive infection involving the para-anal 
tissue is common and surely pyogenic organ- 
isms are always present. Why then is pyogenic 
infection of the apocrine glands of the para-anal 
region so uneommon? In patients consulting 
us for the relief of proctologic conditions the 
incidence of hidradenitis suppurativa is roughly 
one in one thousand. A more careful search 
would have revealed a higher incidence. I am 
led to conclude that some unusual condition is 
present in the apocrine glands of these few 
patients which makes them susceptible to 
pyogenic infection. It may be much like the 
sebaceous glands of the skin of the patients with 
acne vulgaris. 


American Journal oj Surgery 




63 


Christensen — Hidradenitis Suppurativa 


MICROPATHOLOGIC CHANGES 

Sections from all cases reported were ob- 
served histologically. An extensive inflamma- 
tor3'^ reaction near the abscess was observed in 
each instance with a milder reaction as indi- 
cated by scattered groups in lymphocytes in 
the surrounding tissue. 

The glands appear to become infected by 
way of the lymph channels of the subcutaneous 
tissue as well as bj^ surface contamination. 
Normal glands are seen near those diseased. 
Once involved in a destructive process the 
gland appears to be destroj'’ed and does not 
regenerate. 

Fibrosis is evident in the chronic stage. The 
basement membrane is composed of a ver^'' 
thick layer of fibrous tissue cells with near 
normal fat on its deeper surface. Plasma cells 
and lymphocytes are found covering the abscess 
side of the membrane. The greatest destruction 
occurs in the subcutaneous tissue, causing a 
definite undermining process beneath the skin. 

PROGNOSIS 

When only a few isolated glands are infected, 
it is possible that they may drain and spon- 
taneously return to near normal in from ten to 
fifteen days. In all cases, however, the prognosis 
must be guarded because as occurred in some 
of these cases reported the patient had remis- 
sions of the inflammatory process and further 
operative procedures were necessary. 

It has been observed that when an area of 
active disease was resected and healing occurred, 
other areas of lesser involvement would often 
improve. In my judgment the patient who has 
a chronic sinus will avoid a more extensive 
operation and possibly forestall the spread of 
the disease by having an earK'^ excision of the 
involved tissue. 

TREATMENT 

The patients here reported came to our 
office because they had a draining para-anal 
sinus. They were, therefore, all advanced 
chronic cases and in general the treatment con- 
sisted of surgical removal of the involved 
glands followed by eontinued local treatment 
and removal of anj'^ glands subsequently’^ 
infected. 

In 1939 Brunstingi suggested such general 
methods of treatment as incision of the indi- 
vidual abscess followed by’ filtered roentgen 
ray’s and administration of sulfanilamide in 
those cases in which hemolytic streptococcus 

January, tgyo 


was found to be the infecting organism. Non- 
specific therapy, including the use of dessicated 
thy’roid and autogenous vaccine, was of little 
value. He further stated that in the advanced 
case excision of the gland-bearing skin and 
involved tissue was necessary, followed by- 
skin grafts when indicated. Sutton-* and 
Brunsting warn against the use of ointments 
and suggest the use of i per cent phenol with 
1:5,000 bichloride of mercury in 70 per cent 
alcohol. 

In my own experience large doses of penicillin 
will reduce and thicken the discharge and will 
quiet down an area of acute inflammation but 
it will not bring about healing of the multiple 
sinuses. Penicillin may be of value, therefore, in 
treating a patient during an acute attack of the 
disease following which the involved tissue can 
be excised. 

Treatment will vary'- with each patient de- 
pending upon the extent of involvement. One 
or more acutely infected glands may heal; but 
when the process is extensive and many- 
openings are present, it should be removed 
en hloc. The wound is grossly infected; and 
since this region is contaminated repeatedly, 
closure is not attempted. The process does not 
e.xtend deeper than the subcutaneous fatty’ 
tissue and, therefore, no important structures 
are encountered. The wound should be thor- 
oughly explored for side tracts beneath the 
skin edge and all edges beveled so as to sau- 
cerize the wound. Scarring is no problem in the 
peri-anal area so it is not necessary to do any 
skin grafting in this region. 

The wound may be covered with dressings 
wet with mild antiseptics. Later, wet dressings 
and hot sitz baths may be used until healing is 
complete. The use of silver nitrate to control 
areas of excessive granulation tissue is neces- 
sary. The wounds usually’^ fill in rapidly'. 

Involvement of new areas or separate glands 
may’ oceur at any time requiring immediate 
excision. 

CONCLUSIONS 

Attention is called to py'ogenic infection of 
the peri-anal apocrine glands. Patients with 
this condition come to the proctologist because 
the advanced lesions simulate anal fistulas. 

Eight cases are reported; all were advanced 
cases exhibiting fistula formation. Our treat- 
ment was excision and satisfactory’ results were 
obtained. The patient is warned of the likeli- 
hood of recurrence and involved areas should 
be excised if suppuration occurs. 



Christensen — Hiclradenitis Suppurativa 


6 . 1 - 


KEFERENCES 

1 . Brunsting, H. a. Hidradenitis suppurativa; abscess 

of the apocrine sweat glands; a study of the clinical 
and pathologic features, with a report of 22 cases 
and a review of the literature. Arcb. Dermal. & 
Sypb., 39; 108-120, 1939. 

2. Smith, N. D. Pyoderma simulating e.\tensive anal 

fistula. Tr. Am. Prod. Soc., 39: 163-176, 1938. 

3. Jackman, Raymond J. Hidradenitis suppurativa; 

diagnosis and treatment of its perianal manifesta- 
tions. Am. J. Digest. Dis., 9: 220-222, 1942. 

4. Sutton, R. L., Sr. and Sutton, R. L., Jr. Diseases 

of the Skin. Ed. 10, p. 1444. St. Louis, 1935. C. V. 
Mosby Co. 

DISCUSSION 

N. D. Smith (Rochester, Minn.): I have enjoyed 
the privilege of studying Dr. Christensen’s paper 
and I am impressed the fact that there can be 
little disagreement with his basic observations and 
conclusions. Most of the members of this Society, I 
believe, are keenly aware of the occurrence of such 
lesions and understand the underlying pathologic 
process. Also, all seem to agree that surgical ex- 
cision is the best or only curative therapy at 
present. The newer chemical or antibiotic agents 
and physical therapeutic efforts accomplish little, 
if any, temporary improvement and they probably 
do not alter favorably the ultimate progress of the 
disease. Such measures seem to postpone curative 
measures and unnecessarily add to the patient’s 
financial expenditure. 

In those cases in which it is necessary to remove 
large portions of skin a subsequent skin graft will 
assist materially in reducing the healing time and 
also will improve the result. 

I w’ould like to correct one misinterpretation. 
Dr. Christensen, in mentioning an article presented 
to this Society in 1938, said that I stated “that 
one case was thought to be hidradenitis suppura- 
tiva.” I meant, however, not that this case was the 
only one of hidradenitis suppurativa among the 
cases which I presented but that in the case 
referred to distribution of the disease was especially 
typical. Lesions were in the perianal, gluteal and 
labial regions, in the groins, under the breasts and 
in the axillas. 

We are indebted to Dr. Christensen for present- 
ing this paper which is informative and practical 
and in which he included enough case reports to 
illustrate the clinical aspects of the disease. 

R. E. Pumphrey (Dayton, O.): I have enjoyed 
Doctor Christensen’s brief presentation of an 
interesting condition. He has outlined the impor- 
tant features of the disease and indicated the 
proper therapy. His case reports are representative 
of the disease and illustrate the involvement of 
other parts of the body, most frequently the axillas. 

Much in the w’ay of speculation concerning the 
actual mechanism of the disease could be added 


but this Doctor Christensen has wisely refrained 
from doing. There are many questions that cannot 
be answered in the light of our present knowledge. 
We know that the apocrine glands are compound 
tubular glands which usually open into a hair 
follicle and that they function by rupture of the 
cell membrane, the cellular protoplasm forming 
a thick secretion of unknown composition. They 
arc not activated until puberty and tend to become 
infected in persons having an oilj’’ skin and the 
so-called acne diathesis. The disease may be 
initiated by the infectious processes associated with 
a fistula-in-ano or pilonidal disease. Aside from 
these facts, most of us arc not prepared to explain 
exactly why a given individual has the condition. 

Doctor Christensen has mentioned how often 
this disease is confused with fistula-in-ano. His 
point is well taken and his description of the 
patchy, irregular, brawny infiltration of the in- 
volved tissues with multiple draining sinuses 
should easily guide us to the correct diagnosis. 
Doctor N. D. Smith has pointed out a good diag- 
nostic feature, the clear, uninvolvcd area that is 
usually present in the tissue immediatcl}’- adjacent 
to the anal verge. This is especially demonstrable 
in the advanced cases which arc the ones with 
which we arc particularly concerned. It is also 
worthj’’ of mention that a search for fistula-in-ano, 
pilonidal disease, etc., should always be made, even 
in the face of typical hidradenitis, since all of us 
have found them in association on occasion and 
correction of the usual case of hidradenitis does not 
effect cure of the fistula. We should also inspect 
the crypts carefully so as to avoid the recurrence 
of a lymphatic abscess as described bj' Buie. 
Careful study of the individual cases will reveal 
the e.xtcnt of the disease, therebj' avoiding needless 
surgery and yet being sure of adequately dealing 
with the existing disease. Mention is also made 
in the literature of tumor formation involving these 
glands; these hidradenomas are thought by some 
to be carcinomas. However, metastases has not 
been demonstrated and local excision has been 
curative. 

In conclusion I should like to thank Doctor 
Christensen for his excellent presentation. I 
believe we have all profited by the renewed con- 
sideration of this disease. There is no doubt that 
early recognition of the condition can greatly 
reduce its morbidity and that proper surgery can 
lessen the sequellae. An intelligent understanding 
of the disease by the patient will also do much to 
promote a cordial patient-doctor relationship if 
and when another gland flares up. 

Mark M. Marks (Kansas City, Mo.): I enjoyed 
listening to Dr. Christensen’s paper. We have been 
friends for a long time and have had opportunities 
to argue various phases of the subject. In a paper 
read before the Southern Medical Association 
which convened in 1945 in St. Louis, Missouri, I, 

American Journal of Surgery 



Christensen — Hidradenltis Suppurativa 


65 


too, recorded a large series of cases of this type to mode of metabolic failure and warned against 
which came under my care while in military service, excessive use of fats, both vegetable and animal. 
From these cases certain conclusions were reached. In April, 1943, Dr. Richard Sutton, Jr, and I 
Hj'’dradenitis suppurativa and acne conglobate, reported a case of perianal pyoderma and acne 
postauricular sebaceous cyst, saddle sores and conglobate in the Journal of the American Medical 
steatoma of the scrotum are all related in that thej”^ Association. The patient had a very extensive 
are local evidences of systemic disease. This was involvement of the neck, axilla, hips and buttocks, 
proved by a consistent clinical picture of low basal The patient had been drinking three quarts of milk 
metabolism, chronic fatigue and hypercholester- daily. When his diet was corrected, when sufficient 
emia which ranges from 178 to 400 mg. per cent. thyroid was given to raise basal temperature to 

Because of the chronic fatigue it was found all normal and with the addition of ammonium 
of these people were eating foods rich in lipids chloride, satisfactory healing occurred without 
which were deposited in the apocrine and the interruption. It is important to remember that 
sebaceous glands. In the treatment of these pa- perianal lesions like other manifestations arc 
tients it is imperative that they be instructed as evidences of systematic conditions. 




January, ig$o 



THE SURGICAL PATHOLOGY OF' RECTAL CANCER 

CuTHBERT E. Dukes, m.d. 

London, England 


AN English visitor to the United States 
of America is bound to be overwhelmed 
at first by the realization of what a 
lot the Old World has to learn from the New, 
especially in the organization and application 
of scientific knowledge. I have been very 
conscious of this when studying the organiza- 
tion of pathologic services in your hospitals 
which fill me with admiration and envy. Even 
in the special subject on which this article is 
based, I know full well that 1 have learned 
much in the past and am still learning from 
American pathologists and surgeons. 

At the same time I venture to think that I 
have something to give in return because for 
twenty-five years I have been in charge of the 
Department of Pathology at St. Mark’s Hos- 
pital, London, a special hospital for the treat- 
ment of diseases of the rectum and colon. Soon 
after I was appointed pathologist to this 
hospital in 1923 I developed a method of 
examining specimens of intestinal cancer so 
as to learn as much as possible in each case 
about the origin, structure and spread of the 
tumor. I have been fortunate in having been 
able to continue this work without interruption 
over a long period, so that in more than 3,000 
cases full details are now available as to the 
size and position of the primary tumor, the 
extent of local and venous spread, and the 
exact number, size and position of all lymphatic 
metastases. This experience has led us at St. 
Marks to adopt a threefold classification of 
intestinal cancer based on the gross character- 
istics, histology and extent of spread of the 
tumor. This has proved to be of special value 
from the point of view of prognosis after 
surgical treatment. 

FIXATION OF OPERATIVE SPECIMENS 

In the first place I must stress the importance 
of the initial treatment of an operative speci- 
men because much useful information can be 
gained by a good look at the outward appear- 
ance of an intestinal tumor. The size, shape and 
color of a tumor, its apparent extent of spread 
and the amount of free margin around are all 


details of surgical - interest and may have 
significance in relation to prognosis. It must be 
admitted, however, that often these details are 
not observed because the operative specimen 
has been improperly treated and either muti- 
lated by a surgeon or ruined by a pathologist. 
Both should know that the best view of a 
tumor can be obtained only when the operative 
specimen has been pinned out or distended, 
then fixed and washed clean. A surgeon who 
slices open a tumor in the theater “just to have 
a look at it” gets a poor view himself and 
obscures the view still more for others. In like 
manner, a pathologist who plunges an operative 
specimen into formalin before taking steps to 
prevent shrinkage and distortion is making a 
mistake which cannot be rectified afterward. 
Since so much depends on the initial treatment 
of an operative specimen, I will describe tlie 
two methods which experience has led us to 
adopt as our routine at St. Mark’s Hospital. 
One consists of stretching out the specimen on 
a frame; the other consists of distending it with 
formalin. 

The stretching out method of preventing 
shrinkage is most suitable for comparatively 
short and straight pieces of bowel such as the 
distal end of the pelvic colon, rectum or anal 
canal. A large basin or sink must be available 
and rubber gloves should be worn. The opera- 
tive specimen is first opened up with scissors, 
care being taken not to cut through the tumor 
if this can be avoided. The edges and ends of 
the bowel are then stitched with thin string 
to a framework of Meccano perforated strips 
(Fig. i), after which the stretched-out specimen 
is immersed in a tall jar or tank containing 
1 0 per cent formalin and left there for a da3'’ or 
two. One advantage of the metal framework is 
that it keeps the specimen submerged. If it is 
pinned out on a cork mat or wooden board, it 
must be sunk with weights. 

The distention method is better for tumors 
of the colon, especiallj^ when these are to be 
preserved as museum specimens. The distal 
end of the bowel is ligatured and a glass tube is 
inserted into the proximal end and secured in 

66 American Journal of Surgery 


Dukes — Rectal Cancer 


67 



I 2 3 

Fig. I. Operative specimen stretched out on frame for fixation. 

Fig. 2. Photograph of operative specimen and gland dissection showing position of lymphatic 
metastases. 

Fig. 3. Photograph of operative specimen and gland dissection showing spread within lumen of 
veins. 


position with a slip knot. The intestine is then 
distended to natural size with 10 per cent 
formalin run in under gravity from a bottle 
placed on a shelf. When full the operation 
specimen is pulled away from the glass tube, 
the noose being tightened at the same time to 
prevent the formalin solution from escaping. 

These methods of handling operative speci- 
mens have the advantage of displaying a 
tumor in its natural setting. The tumor be- 
comes worth looking at; in fact, it seems to 
come to life. 

EXAMINATION OF FIXED SPECIMENS 

After fixation the subsequent examination 
can be carried out at any convenient time. A 
record is first made of the appearance, size and 
position of the tumor, the quadrants it has 
affected, its relationship to the peritoneal 
reflexion, anorectal line or similar landmark, 
and the length of normal bowel above. 

The specimen is next examined to determine 
the extent of local and lymphatic spread and 
for evidence of spread within the veins. The 
ex-tent of local spread is investigated by cutting 

Januanr, ig^o 


a thin slice with a sharp knife through the 
region of deepest visible extension, the bound- 
aries of the cancerous invasion being usually 
fairly obvious on naked eye inspection of the 
cut surface. Next the lymph nodes are dis- 
sected out from the perirectal fat, a scale 
drawing being prepared to indicate their posi- 
tion. The nodes are then numbered and 
blocked in groups. After microscopic examina- 
tion the position of metastases is marked on 
the diagram by inking in the affected nodes. An 
alternative method is to remove the lymph 
nodes in two groups, namely, (i) those in the 
immediate vicinity of the tumor and (2) the 
topmost nodes situated where the vascular 
pedicle is ligatured. 

If an operative specimen is dealt with in this 
way, it is possible to saj'^ not only how many 
nodes contain metastases but also where these 
were situated. Our practice at St. Mark’s 
Hospital is to attach to the report two photo- 
graphs, one of the operative specimen showing 
the position and size of the primary tumor and 
the other a photograph of a scale drawing 
made after 'dissection. In this the position of 


68 


Dukes — Rectal Cancer 


the primary tumor is indicated by shading 
and the extent of local spread by stippling. 
Lymph nodes not containing metastases are 
merely outlined but cancerous deposits are 
recorded in black. (Fig. 2.) 

The examination of the veins of the operative 
specimen is carried out at the same time as the 
lymph node dissection. The veins draining the 
area of the tumor should be freed from the tis- 
sues in which they are embedded and then 
palpated between the thumb and forefinger. 
Any solid material felt within the vein is 
removed for section; and if it is found to be 
malignant, its position is recorded in the gland 
dissection chart. (Fig. 3.) 

Evidence of extension within veins usually 
assumes the form of a solid cord extending a 
short distance onl3^ The intravascular growth 
preserves its continuity with the primary tumor 
and is no more than a special form of direct 
local extension. It is as if the malignant tumor, 
having found the path of least resistance, has 
pushed a root-like process along the lumen of 
the vein. This is the most common manifesta- 
tion of venous spread but occasional!}' one 
finds also a massive permeation of the hemor- 
rhoidal veins accompanied by thrombosis. 
Intravascular spread is most often found in 
anaplastic varieties of carcinoma being present 
in more than 30 per cent of tumors reported 
as high grade but in less than 3 per cent of those 
marked low grade of malignancy. The veins 
are seldom invaded until the tumor has spread 
by direct continuity through the wall of the 
bowel. 

THREEFOLD CLASSIFICATION OF RECTAL CANCER 

After the operative specimen has been fixed 
and dissected and the sections examined, it is 
possible for the pathologist to collect the 
information which has been assembled stage 
by stage and to adopt a comprehensive classi- 
fication based on the gross characteristics, the 
histology and the extent of spread of the tumor. 
Let us consider each of these in turn. 

Classification Based on Gross Characteristics. 
On the basis of outward appearances we may 
distinguish six varieties of rectal carcinoma, 
namely, malignant adenoma, malignant papil- 
loma, protuberant carcinoma, ulcerating car- 
cinoma, stenosing carcinoma and atypical 
carcinoma. 

The term malignant , adenoma is used to 
describe carcinoma arising in a pre-existing 


adenoma and malignant papilloma a focus of 
carcinoma within a pre-existing villous papil- 
loma. In both malignant adenoma and malig- 
nant papilloma the greater part of the tumor is 
benign and the carcinoma small and early. 
Malignancy results in a darker color, local 
induration and ulceration. 

The ' protuberant type of carcinoma dilTcrs 
from malignant papilloma in malignancy 
throughout. It projects into the lumen of the 
bowel causing partial obstruction. Although 
the growth may be spread over a wide area 
on the surface, there is often little penetration 
into the bowel wall. It is well known that 
protuberant varieties of carcinoma arc slow to 
metastasize and are often of a low grade of 
malignancy. 

Ulcerating carcinoma is the most common 
form of rectal cancer. The ulcer may extend 
over two or three quadrants or completely 
encircle the bowel (annular grou-th). The edges 
are raised and everted and the outline ser- 
pigenous. The depth of ulceration is usually 
proportional to the extent of deep penetration. 
Small, deeply ulcerated carcinomas often 
metastasize early and arc of a high grade of 
malignancy. 

The term stenosing (constricting or scirrhus) 
is applied to a carcinoma which almost ob- 
literates the lumen. 

Atypical carcinoma is a convenient last 
resort. Most intestinal carcinomas fit fairly 
easily into one or another of the five groups 
already mentioned but occasionally tumors are 
encountered which have a very unusual and 
atypical appearance. For instance, in some 
cases the primary tumor is exceptionally small 
or even apparently non-existent; in others the 
only lesion is a stricture or fistula. Atypical 
carcinoma is a useful pigeon-hole for hopeless 
misfits. 

Classification Based on Histology. According 
to its histology rectal cancer can be divided 
into three main groups, namely, adenocar- 
cinoma, colloid carcinoma and carcinoma 
simplex. Each of these has a distinctive histo- 
logic pattern which is of significance in relation 
to prognosis. The chief features of each group 
are as follows: 

Adenocarcinoma (non-mucinous, columnar 
cell carcinoma) is composed of columnar or 
cubical cells arranged for the most part in a 
tubular or acinar pattern, there being no sign 
of mucus secretion either in the cells or glandu- 

American Journal oj Surgery 



Dukes — Rectal Cancer 


69 



4 5 6 

Fig. 4. Adenocarcinoma; low grade of malignancy. 

Fig. 5. Adenocarcinoma; average grade of malignancy. 

Fig. 6. Adenocarcinoma; high grade of malignancy. 



Fig. 7. Colloid carcinoma. 
Fig. 8. Carcinoma simplex. 


lar spaces. This is the most common variety of ing carcinoma) has a similar basic structure to 
rectal cancer. It may be further subdivided adenocarcinoma but differs in that mucus is 
according to the degree of differentiation of the secreted. (Fig. 7.) The mucus gives rise to a 
tumor cells into three subgroups, namely, low “signet ring” appearance when stored in 
grade of malignancy (Fig. 4), average (Fig. 5). individual cells but if secreted into glandular 
and high grade of malignancy (Fig. 6). Our spaces, the epithelial cells are often relatively 
follow-up records show that more than 60 per- few in number and found only at the margin, 
cent of patients with low grade malignancy- Colloid carcinoma is the second most common 
have survived five years whereas less than variety of rectal cancer, composing about 20 
30 per cent of the patients with high grade per cent of all cases. In general it has a worse 
malignancy have lived for this period after prognosis than adenocarcinoma, 
operation. Lymphatic metastases have been The term Carcinoma simple.x is used to 
found in only 18.4 per cent of low grade tumors describe an anaplastic t3’'pe of carcinoma com- 
but in 78.2 per cent in high grade tumors. posed of polygonal or spheroidal cells destitute 
Colloid carcinoma (mucoid or mucus-secret- of any glandular arrangement and not showing 

Janxiar^r, ig^o 



70 


Dukes — Rectal Cancer 


mucus secretion. The tumor cells are scattered Examination of operative specimens of rectal 
about singly or in small clusters or they may be cancer has shown that in about 1 5 per cent of 
arranged in a solid trabecular or alveolar cases the growth is still at the first stage and 
pattern. (Fig. 8.) It may be difficult at first confined to the rectum onh'. In approximately 
to decide whether the growth is a sarcoma or 35 per cent there is some local extrarectal 
carcinoma but some part of the tumor generally spread but no lymphatic metastases and in the 



BUT NO HETASTASES IN REGIONAL LYMPH NODES. 
C- METASTASES IN REGIONAL LYMPH NODES. 


9 10 

Fig. 9. Classification into “A,” “B” and “C” cases according to extent of spread. 

Fig. 10. Subgroups, “C i ” and “C 2.” 

has features characteristic of carcinoma. These remainder the tumor has reached a later stage 
tumors are of a high grade of malignancy, and lymphatic metastases are present. These 
metastasize early and have the worst prognosis proportions have remained fairly constant 
of all. from year to year although varying slightly 

Classification Based on Extent oj Spread, with the operability rates at different periods. 

The system we have used for many years at The influence of local spread can be shown in a 

St. Mark’s Hospital is to classify patients who very convincing way by comparing the 
have been treated by radical e.\'cision into four prospects of patients in the first and second 
groups according to the extent of spread of the stages of the disease, the so-called “A” and 
disease as revealed by the examination of the “B” cases. Between 80 and 90 per cent of “A” 

operative specimen. (Fig. 9.) In the first or patients have survived five years but only 60 

initial stage the gro\\i;h is limited to the bowel to 70 per cent of the “B” cases. These results 

and the patient at this stage is described as an are really very good but unfortunately at 

“A” case. The prognosis after surgical treat- present the prospect for patients with lym- 
ment of such cases is excellent. The second phatic metastases (“C” cases) are far less 
stage is reached when the malignant tumor has satisfactory. 

spread by direct continuity into adjoining Since surxdval after operation depends so 
structures but not yet given rise to lymphatic much on the position of metastases, we have 
metastases. At this stage the patient is de- adopted the plan of dividing patients with 
scribed as a “ B ” case and experience has shown metastases (“C” cases) into two groups. If 
that such patients also have a relatively good the regional nodes alone contain metastases, 

prognosis after surgical treatment. The third a case is described as “C i”; whereas if there 

stage is reached when the malignant growM;h is more extensive lymphatic spread involving 
has spread still further and given rise to also the nodes at the point of ligature of the 
lymphatic metastases. Patients at this stage blood vessels, the case is classified as “C 2.” 
are known as “C” cases. If the malignant (Fig. 10.) This has proved useful because 
growth has spread to distant organs such as patients with only a few regional lymphatic 
the liver, this is described as the fourth stage, metastases have a moderately good prognosis 

American Journal of Surgery 


Dukes — Rectal Cancer 


71 


after radical surgical treatment but with more 
extensive lymphatic spread the prospects of 
cure are not so good. 

The number of metastases is also important. 
Our records for rectal cancer at St. Mark’s 
Hospital show that patients with less than four 
or five l3TOphatic metastases fairlj”^ often 
survive five years but this fifth j'^ear is rarely 
reached by those with more than five metas- 
tases. Therefore, in conclusion a simple, easy 
to remember generalization with regard to 
rectal cancer is given: Patients with five or 
more metastases rarely live for five j'^ears. 

When I was asked to supply an abstract of 
this article in advance, I said that the threefold 
method of e.xamination of operative specimens 


I have described has thrown some light on the 
pathology of rectal cancer and I quoted the 
Chinese proverb “ It is better to light a candle 
than to curse the darkness.” I quoted this 
because it always seems to me that we are 
almost completely in the dark as to the origin 
of rectal cancer and the factors determining 
individual susceptibility or immunity. All that 
we have learned about the natural course of 
this disease has been slowly revealed by the 
experience of surgeons and pathologists who 
have worked with them. This teamwork has 
begun to throw a little light on the prospects 
of the individual patient. Only a glimmer of 
light perhaps, but it may lead to something 
else. Who knows? 




January, 1Q50 



COMBINED ABDOMINOPERINEAL RESECTION* 


Charles W. Mayo, m.d. 
Rodjesler, Minnesota 


T hose interested in surgery of the colon 
and rectum arc familiar with its history. 
The wisdom and progressive thought, the 
considered but daring surgical attacks in the 
light of available knowledge cannot but fill us 
with respect for those pioneers who have 
preceded us in this field. 

The one-stage combined abdominoperineal 
resection was being performed at the turn of 
the last century. I take the liberty of quoting 
as follows from a paper written by m3' father 
entitled “Cancer of the Large Bowel,” pub- 
lished in 1904 in the “Medical Sentinel”: “The 
combined abdominal and perineal method is 
now advocated for high rectal carcinoma b3' the 
pioneers in rectal surger3', Kocher, Kraske, 
Gaudier, Quenu, Trendelenburg, Abbe, Weir 
and numerous others.” He went on to describe 
the one-stage combined operation as it was 
performed by him which description, with 
minor changes in detail, I could present toda3' 
as the method I use. Another quotation from 
that paper which might be mentioned because 
of renewed interest in the synchronous com- 
bined abdominal and perineal operation fol- 
lows: “If the surgeon has a good assistant, the 
perineal operation, with the removal of the 
rectum, can be performed by him during the 
time the abdominal work is advancing above.” 

To Miles must go great credit for extending 
the application of the combined abdomino- 
perineal operation to include low rectal lesions. 
He did this in spite of criticism for the majorit3' 
of surgeons advised and practiced less extensive 
surgical procedures performed from below. 
Also to Miles goes credit for selling an excellent 
technic, namely, the Miles operation. Mr. 
Swinford Edwards in his presidential address 
before the British Proctologic Society in 1913 
had this to say: “Mr. Miles, we all know, prac- 
tices the combined operation in practically all 
cases of rectal carcinoma. . . . Now, mark 
you, this extensive removal of the parts, 
accompanied as it is by a big immediate 
mortalit3', does not abolish recurrence, for I 
understand that already recurrence has oc- 


curred in several cases submitted to this perhaps 
most formidable operation in the whole range 
of surgery. ... A small growth situated low 
down docs not, in m3' opinion, need a combined 
operation; so also, carcinoma at the recto- 
sigmoidal junction cannot be thoroughl3' and 
satisfactoril3' removed b3' a perineal excision.” 

I read with great interest in the Section of 
Proctolog3' of the Proceedings of the Ro3'al 
Society of Medicine for December, 1948, the 
discussion on radical excision of carcinoma of 
the rectum with conservation of the sphincters 
and noted with pleasure and some surprise that 
differences of opinion still are allowed to exist 
and be expressed despite the government’s 
participation in medical care. Each colonic 
surgeon is a champion of certain given methods 
and t3'pes of technic. There are those who 
believe in the “ail or none” law and also those 
who honestly believe that in selected instances 
cancer of the upper portion of the rectum and 
lower portion of the colon is amenable to 
surgical procedures which permit preservation 
of the sphincters. 

No one is entitled to express more than a 
personal opinion relative to the merits or 
demerits of a given operative technic for a 
given condition. In substance a procedure ma3' 
be the same as another but in detail there may 
be as man3' types of one-stage combined ab- 
dominoperineal resections as there are surgeons 
performing the operation. Perhaps the principal 
value of a review of cases is that derived b3' the 
author from a careful anaE'sis of his own 
personal experience and ne,xt from a critical 
interpretation of the work of others for the 
improvement of his own efforts. 

Prior to World War ii I was of that school 
which believed and practiced one-stage com- 
bined abdominoperineal resection for all re- 
movable malignant lesions of the rectum, 
rectosigmoid and lower portion of the sigmoid. 
On my return from militar3' service I reviewed 
266 cases of non-palliative resections that I had 
performed five or more years previously and 
divided them into two groups, nameR', those 


From the Division of Surgery, Mayo Clinic, Rochester, Minn. 

72 American Journal of Surgery 



73 


Mayo — Abdominoperineal Resection 


in which nodal involvement was present and 
those in which there was no nodal involvement. 
Coincidentally, there were 133 cases in each 
group. In the group in which nodal involvement 
was not present the three-year survival rate 
was of 86.3 per cent and the five-year survival 
rate was 72.5 per cent. In the group in which 
lymph nodes were involved the three-year 
survival rate was 57 per cent and the five-year 
survival rate 38 per cent. Although these 
figures from a comparative standpoint seemed 
to agree fairly well with published data, my 
studies of the careful work of others on lym- 
phatic spread of malignant lesions in these 
regions began to influence me to consider 
whether in “the light of present knowledge” it 
was not possible to perform operations that 
would be sufficientlj'- radical in selected cases of 
careinoma of the upper portion of the rectum, 
the rectosigmoid and the lower portion of the 
sigmoid and yet would preserve the sphincters 
and lessen morbidity without increasing the 
mortality rate or unfavorably influencing the 
prognosis. Cautiously at first but with increas- 
ing frequency I have found myself adopting 
the low anterior segmental resection with 
end-to-end rectosigmoidostomy as the proce- 
dure of choice for the majority of these lesions. 
Although there is some variation as to technical 
methods and differences of opinion as to 
whether a concomitant colostomy should or 
should not be performed, the tendency of my 
colleagues in this field of surgery at home also 
has been along this line. 

All patients who have malignant lesions of 
the rectum, rectosigmoid and lower portion 
of the sigmoid are prepared preoperatively 
both mentally and physically for a one-stage 
combined abdominoperineal resection. If the 
lesion is situated in whole or in part in the first 
5 cm. of the rectum from the dentate margin 
and if abdominal exploration justifies it, I am 
certain that the method of attack will be a 
one-stage combined abdominoperineal proce- 
dure. As the distance between the dentate line 
and the growth increases beyond the first 5 cm. 
of the rectum, with increasing frequency I 
perform an anterior resection without con- 
comitant colostomy. The surgical mortality 
rate in my own cases performed after this 
method compares favorably with that of my 
cases of combined abdominoperineal resection; 
it is 4.3 per cent in ninety-four cases. The 
duration of illness after operation is so greatly 
reduced after anterior resection that it is not 


comparable for the two groups; two-thirds of 
the patients subjected to anterior resection 
usually are out of the hospital within two weeks 
of the date of operation. While sufficient time 
has not elapsed since the operation in my cases 
so that I can make an authoritative statement 


Table i 

ONE-STAGE COMBINED ABDOMINOPERINEAL RESECTION 


Year 

Patients 

Hospital Deaths 

Number 

Per Cent 

1908-1919 

21 

6 

28.6 

1920-1929 

29 

8 

27.6 

1930-1939 

169 

28 

16.6 

1940-1948 

1,095 

40 

3.6 

Total 

1,314 

82 

6.2 


about the period of survival in this group, 
Dixon’s analysis (unpublished data) of his 
series of cases demonstrates that the prognosis 
as to length of postoperative survival compares 
favorably with that in cases of combined 
abdominoperineal procedure. 

Although this paper is not supposed to con- 
cern itself with any procedure other than com- 
bined abdominoperineal resection, it has seemed 
necessary to touch briefly on the aforemen- 
tioned technic to indicate the changing 
tendency. 

As individual surgeons we select our own 
method of dealing with a given individual 
lesion. When I might select a low anterior 
resection for carcinoma of the upper portion 
of the rectum, another surgeon might select 
the so-called pull-through procedure as Bacon 
and Babcock of Philadelphia and my col- 
leagues, Waugh and Black, often do. It has 
been my observation that those who criticize 
these procedures most have seen them per- 
formed the least and have utilized them the 
least because they are unalterably opposed 
to them. The fact that recurrences have been 
seen after operations performed by other 
surgeons should not, of necessit3% cause con- 
demnation of a method because who among us 
have not seen recurrences after our own well 
performed operations? 

The one-stage combined abdominoperineal 
resection is a great operation and will remain 
as one of the fine contributions to colonic 
surgery. The following study of cases of this 


January, IQ50 



74 


Mayo — Abdominoperineal Resection 


nature in which operation has been performed 
at the Mayo Clinic is presented with the hope 
that it may be of interest. By no means does it 
answer all the questions relative to the subject; 
but if it only emphasizes by repetition already 
known but important points, it will have 
served its purpose. 

Taui.e II 

HOSPITAL MORTALITY RATE BY AGE AND SEX AFTER 
ONE-STAGE COMBINED ABDOMINOPERINEAL RESECTION 


Mospital Mortality 


Age 

Per cent 

20-29 

. . . 6.2 

30-39 

• 5-3 

40-49 

. 6.1 

50-59 

■ ■ 5-7 

60-69 

... 8.4 

70 + 

... 5.6 

Total 

. . . 6.2 

Males 

. . . 7.1 

Females 

••• 5 3 

From the year 1908 through 

1948 the 


Stage combined abdominoperineal resection 
was performed at the clinic in 1,316 cases with 
an over-all hospital mortality rate of 6.2 per 
cent. (Table i.) 


Table hi 

ONE-STAGE COMBINED ABDOMINOPERINEAL RESECTION 
FOR MALIGNANT LESIONS OF THE LARGE INTESTINE* 


Grade of Malignancy 

Total 

1 

Metastasis 

Num- 

ber 

Per cent 


360 

510 

107 

62 

21 

1 16 

255 

71 

41 

8 

32.2 

50.0 
66.4 

66.1 

38.1 





Total 

1,060 

491 

46.3 



* Grade of malignancy (Broders) and incidence of 
metastasis; 1908 through 1946. 


Separation of cases into groups according to 
sex revealed an almost exact ratio of two males 
to one female, with a somewhat lower operative 
risk for females. (Table ii.) 

As might be expected the greatest percentage 
of persons who have malignant lesions of the 
colon and rectum are between the ages of fifty 
and seventy years. There is no significant 
difference in operative risk in the various age 
groups except that risk after the age of seventy 


years is relatively low as shown in the hospital 
mortality rate in this series. (Table ii.) 

Grade ii lesions, graded according to 
Broders’ method, predominate; the higher the 
grade the greater the incidence of metastasis. 
(Table iii.) Metastatic involvement of lymph 


Table iv 

ONE-STAGE COMBINED ABDOMINOPERINEAL RESECTION 
FOR MALIGNANT LESIONS OF THE LARGE INTESTINE* 


Grade 

Patients! 

Lived Five or 
More Years 
After Leaving 
Hospital 

Total 

Traced 

Num- 

ber 

Per 

cent of 
Traced 
Pa- 
tients 

Without metastasis 

I and II 

100 

12 

7 

95 

12 

7 

66 

7 

6 

69.5 

58.3 

85.7 

HI and IV 

Grade not stated 

Total 

119 

1 14 

79 

69.3 


With metastasis 

1 and II 

03 

28 

6 

59 

27 

6 

26 

5 

2 

44 - • 

18.5 

33-3 

Ill and IV 

Grade not stated. . . . 

Total 

97 

92 

33 

35-9 

Tota! series 

216 

206 

1 12 

54-4 



* Five-year survival rates by metastasis and grade 
of malignancy. 

t Inquirj' as of January i, 1946. Included are only 
those patients operated upon five or more years prior to 
the time of inquiry, that is, 1940 or earlier. Hospital 
deaths are omitted from the calculations. 

nodes is determined at the clinic by examina- 
tion of a minimum of twelve nodes. 

Regarding the survival rate it is interesting 
to note that when a patient has survived five 
years after an operation for malignant lesion 
of the colon and rectum, the chance of his 
surviving for a period of normal life e.xpectancy 
is equal to or slightly better than that of the 
average person; the reason for this is that the 
condition from which death might have 
resulted has been removed in time. If the 
patient survives the operation and if the resec- 
tion has completely removed the involved 
tissue, the prognosis is alwaj'-s good, barring 

American Journal oj Surgery 





Mayo — Abdominoperineal Resection 


75 


the coexistence of other ultimately fatal 
conditions. 

The prognosis should not be based on only 
one factor such as the grade of malignancy. 
Alanjf factors must be taken into consideration 
such as the grade according to Broders’ 


Table v 

ONE-STAGE COMBINED ABDOMINOPERINEAL RESECTION 
FOR MALIGNANT LESIONS OF THE LARGE INTESTINE* 


1 

Age 

(yr.) 

Patientsf 

Lived Five or More Years 
After Leaving Hospital 

Total 

Traced 

1 

Number! 

Per cent of 
Traced Patients 

40 

36 

34 

15 

44. 1 

40-49 

64 

61 

35 

57-4 

50-59 

80 

77 

48 

62.3 

60 -f- 

36 

34 

14 

41.2 

Total 

216 

206 

I 12 

1 

54-4 


* Five-year survival rates according to age. 

t Inquiry as of January i, 1946. Included are only 
those patients operated upon five or more years prior 
to time of inquiry: that is, 1940 or earlier. Hospital 
deaths are omitted from the calculations. 

method, the extent of mural penetration of the 
cell according to Dukes’ classification, nodal 
involvement, distant metastasis, involvement 
of veins, the location of the lesion, the degree of 
obstruction and the age of the patient. The 
five-year survival rates are based on two of 
these factors, the grade and metastasis. 
(Table iv.) 

Youth long has been known to affect the 
prognosis adversely, probably on the basis of 
richer blood and lymphatic supply. However, 
it is not to be e.\'pected that the five-year 
survival rate will be high in the older age 
groups despite the fact that the operative risk 
is surprisingly low. (Table v.) 

If one were to pick a location in the rectum 
about which there is little controversy at 
present as to the selection of a type of opera- 
tion, it would be the first 5 cm. above the 
dentate margin of the anus. If a carcinoma lies 
in whole or in part within this limit, with rare 
exception high, low and wide resection is 
essential; the operation which I prefer in such 
cases is one-stage combined abdominoperineal 
resection. Malignant lesions in the low'er 

January, ig§o 


portion of the rectum notoriously carry a 
poorer prognosis than those in the upper 
portion of the rectum, the rectosigmoid and 
the sigmoid. I am of the opinion that the 
posterior part of the resection can be performed 
as radically by the one-stage as by the two- 
stage operation and that it is not necessary to 
sacrifice the coccyx. The time that the malig- 
nant lesion remains within the body is mini- 
mized by the one-stage procedure which must 
be an important factor from the standpoint 
of the development of metastasis not to men- 
tion the fact that morbidity also is decreased 
by this procedure. 

In order to study this matter of the method 
of attack and the survival rate from another 
vie-wpoint DeWeerd and I have just completed 
an unpublished review of 234 traced cases in 
which lesions were situated in the first 5 cm. of 
the rectum and in which loop colostomy and 
later posterior resection in the Kraske position 
had been performed, at one time a favored 
operation for rectal carcinoma. According to 
our findings nodal involvement was present in 
41 per cent; of these only 19 per cent of the 
patients survived five years or longer. 

We compared this with a study of ninety- 
three traced patients who had undergone the 
usual type of one-stage combined abdomino- 
perineal resection for malignant lesions situated 
in whole or in part within the first 5 cm. of 
rectum above the dentate margin. In this 
group nodal involvement was present in 46 per 
cent of the cases; of these 23 per cent of the 
patients survived five years or longer. 

In conclusion and in the light of present 
knowledge it would’ appear to me that a 
properly performed one-stage combined ab- 
dominoperineal resection for malignant lesions 
in the rectum, rectosigmoid and lower portion 
of the sigmoid is a radical operation which has 
proved to give excellent results when all factors 
are considered. I believe it will continue to be 
the operation of choice for malignant lesions 
of the lower portion of the rectum and for 
man3’^ of those in the upper portion of the 
rectum. There is, how’ever, a tendencj% which 
I predict will grow, to adopt sphincter-saving 
operations in the majoriU’- of cases of malignant 
lesions in the upper portion of the rectum. I 
believe the time will come when combined 
abdominoperineal resection will be performed 
rarely for those lesions situated in the recto- 
sigmoid or higher. 



PERINEO'ABDOMINAL EXCISION OF THE RECTUM 

IN ONE STAGE 


William B. Gabriel, m.s., f.r.c.s. 
London, England 


A COMBINED radical excision of the 
rectum and pelvic colon is the best 
operation for an established rectal 
carcinoma at any level. This is a sincere and 
firm expression of my belief and practice 
founded on an e.xperience with this disease 
since 1919 when I first became attached to 
St. Mark’s Hospital, London. 

The present controversy about the treatment 
of cancer of the rectum and rectosigmoid ser\ms 
to remind us of the rise and fall and periodic 
change in surgical opinion that seems to take 
place from time to time. The situation now is 
in some ways comparable to what happened 
about forty years ago when conservative 
resections were tried for a time and were then 
abandoned. 

There is little doubt that the retesting of 
these conservative methods which has been 
made in recent years involves a greater number 
of patients than has ever before been subjected 
to these operations, whether the resections have 
been anterior or posterior, abdominoanal or 
abdominosacral — methods which, personallj% I 
regard as dangerous, retrograde and not in the 
true interest of the patient except in the most 
exceptional circumstances. It is important and 
indeed essential that priority and the fullest 
publicity should be given to articles reporting 
immediate and late results after conservative 
resection for cancer of the rectum; information 
is needed as to the amount of continued 
hospital treatment and supervision required 
after recovery from the primary operation, and 
facts regarding the incidence and management 
of pelvic recurrences. 

It is important that a general view of the 
situation should be obtained and possibly a 
survey such as that published by the British 
Empire' Cancer Campaign (Annual Report, 
1946) or by E. J. Ottenheimer' of the Division 
of Cancer Research of the Connecticut Depart- 
ment of Health will be needed. Cooperative or 
group statistics such as these Include cases from 
many general hospitals and give a salutary 


picture of what is being accomplished regarding 
both hospital mortality and end results. 

In his book, “Diseases of the Rectum and 
Anus,” my senior colleague, Mr. J. P. Lockhart- 
Mummery, wrote in 1914: 

“Choice of Operation. — ^The question as to 
which operation is the best for the removal 
of the rectum is one on which there is much 
dllference of opinion; but the general tendency 
of recent years has been to advocate much 
more e.xtensive operations, and to advise that 
the abdomino-perineal operation should be 
performed in the majority of cases. This is in 
accordance with the results of recent stud\' 
of the lymphatics of the rectum, which lead 
us to believe that the more freely these lym- 
phatic areas in the neighbourhood of the reetum 
are removed, the better chance is there of the 
subject being free from recurrence. Most 
surgeons now agree in recommending complete 
removal of the rectum in all cases when this 
operation can be carried out. Mr. W. Ernest 
Miles, Mr. Sampson Handley, Mr. Gordon 
Watson, and myself, have all recently pub- 
lished papers describing more extensive oper- 
ations in dealing with cases of caneer of the 
rectum. There can be no doubt that the best 
results will be obtained by complete removal 
of the rectum in all cases.” 

I believe this opinion is as sound and true 
today as when it was written. The object of this 
article is to remind you of some basic and 
incontrovertible facts regarding rectal cancer, 
facts which are ine.xorabIe and recurrent. 

Compared with those days we now have the 
great advantages of improved surgical methods 
with better preparation and after-care, better 
anesthesia and all the methods of reducing 
postoperative complications (of these I would 
specially name the sulfa drugs, penicillin and 
stainless steel wire), but the position regarding 
cure of rectal cancer is basically unchanged. 

In spite of present knowledge of the pa- 
thology of rectal cancer, of lymphatic and 
venous spread and of histologic grading, we 

76 American Journal oj Surgery 



Gabriel — Excision of Rectum 


77 



Fig. I. Two examples of small primary carcinomas of the rectum with exten- 
sive extrarectal spread. 



Fig. 2. Three examples of discontinuous or interrupted upward lymphatic spread. 


cannot assess Jor certain the extent of local and 
lymphatic spread at the time of operation in 
any given case either by clinical examination 
or laparotomy. While some large and appar- 
ently fixed growths turn out better than 
anticipated owing to inflammation or abscess 
formation at the base of the tumor, many small 
growths which clinically appear to be very 
early, in reality prove to be much more exten- 
sive than originally suspected, with marked 
lymphatic spread. (Fig. i.) A routine radical 
excision is therefore likely to be the best treat- 

January, 


ment for these small growths as well as for the 
clinically advanced ones. 

Important pathologic investigations on lym- 
phatic spread have been done in recent years in 
America, particularly those by Gilchrist and 
David* Coller, Kay and MacIntyre,* and 
Glover and Waugh. ^ We are all agreed that 
downward lymphatic spread is unusual and is 
evidence of a late stage of the disease. But this 
does not absolve us from the dutj’^ of carrying 
out the widest possible excision in the line of 
the upward lymphatic spread and also of the 



78 


Gabriel — Excision of Rectum 



Fig. 3. Massive rectosigmoid careinoma 12 inches in circumference safely removed by tlic perineo- 
abdominal route. 

Fig. 4. Rectosigmoid carcinoma plus involved loop of ileum removed by perinco-abdominal excision; 
uninterrupted recovery. 


lateral spread, particularly when the primary 
growth is in the rectal ampulla. 

From the lymphatic standpoint one addi- 
tional reason for the routine removal of the 
longest possible length of the superior hemor- 
rhoidal pedicle is the risk which is not full}’’ 
realized of discontinuous upward spread. This 
term describes those cases in which the malig- 
nant cells owing to an unusual arrangement 
of the trunk lymphatics have jumped the 
intermediate stations, so to speak, and have 
produced metastases in the uppermost nodes 
but not in a continuous chain. This finding is 
not at all uncommon (Fig. 2) and cannot be 
detected either clinically or at operation. It 
remains for the pathologist to demonstrate 
what has happened; and if a combined excision 
has been done, the surgeon can rest content 
in the knowledge that he has done his best 
for the patient. (Figs, i and 12.) 

Lymphatic spread, however, is not the only 
problem to be considered. When an organ 
develops a malignant growth, it is best, if its 
situation allows, to remove it intact and com- 
pletely. A close analogy may be drawn between 
the breast and the rectum. In both situations 
multiple tumors are liable to develop and, 
therefore, a partial or segmental resection is to 
be deprecated in view of the risk of another 
cancer developing in the portion left. In the 
case of the rectum we alreadj’’ know that a 


partial removal, for instance in Flartniann’s 
operation, may be followed by the development 
.of a second malignant growth in the segment 
of rectum that has been left, whether by im- 
plantation or as an independent second primary 
tumor it may be difficult to determine. The 
same development is liable to occur after 
conservative resection in which any portion 
of the rectum or pelvic colon is left. The risk of 
implantation recurrence which has occurred 
even in the earlj-^ A cases after restorative 
resection has been clearly indicated bj' O. V. 
Lloyd-Davies^ in a very frank and informative 
paper. This catastrophe, namely, local recur- 
rence in A cases, is absolutely unheard of after 
radical excision. 

Then there is the question of adenomas or 
mucosal polyps of the rectum. It is just over 
twenty years since J. P. Lockhart-Mummery 
and Cuthbert Dukes® published their oft- 
quoted paper on adenomas and their relation 
to malignancy. The subject was fullj’’ dealt 
with before this Societj’^ in 1947 bj'^ G. E. 
Binkley and D. A. Sunderland^ and by N. W. 
Swinton.® Our President in collaboration with 
G. G. Broad® has described many important 
points in the incidence and pathogenesis of 
adenomatous polyps and their relation to 
malignancy of the large bowel. There is not the 
least doubt that the heavy incidence of both 
adenomas and carcinomas in the rectum and 


American Journal oj Surgery 



Gabriel — Excision of Rectum 


79 



Fig. 5. Two abnormally short, bulky specimens; they measured only 12 and 13 inehcs, respec- 
tively, from the anus to the iliac colon. 


rectosigmoid is of great significance and supreme 
importance surgically. 

The accepted figure for incidence, I would 
remind you, is that 80 per cent of all intestinal 
cancers are located in the sigmoid and rectum; 
by radical excision of the anus, anal canal, 
rectum and pelvic colon up to a left iliac 
colostomy we can remove the growth together 
with the regions more dangerously liable to 
malignant disease than any other part of the 
large bowel. At the same time we can eliminate 
both the present and the future risk of other 
epithelial tumors developing in this region. 

I do not admit that a colostomy is a grave 
disability. A very large number of patients 
have been questioned in my clinics as to their 
reaction to colostomy life; the majority states 
that “the colostomy causes no trouble” or 
“the amount of inconvenience caused by the 
colostomy is very trivial” or some such expres- 
sion. One enthusiastic patient recently told me 
“the colostomy is wonderful, morning and 
night, and no bother.” I have no hesitation in 
saying that as a group with few exceptions 
patients with a colostomy after radical excision 
of the rectum are active, useful and contented 
members of society able to work hard and carry 
out their usual avocations just as before the 
operation except, of course, when advancing 
years gradualb^ slow down the tempo of their 
lives. 

A permanent terminal colostomy at the site 
of election should therefore be considered a 


small price to pay for a perfect, complete 
radical operation which meets all pathologic 
requirements. The mortality is now very low 
and the advantages conferred are great, par- 
ticularly the prospects of cure, the rarity of 
pelvic recurrences, the avoidance of complica- 
tions and the need for only very occasional 
supervision once the immediate postoperative 
period has been passed. These patients are not 
hospital chronics, in and out of hospital at 
frequent intervals, but fit, healthy and inde- 
pendent members of the community. 

TECHNIC OF PERINEO-ABDOMINAL EXCISION 

The technic of this operation in one stage has 
been fully described elsewhere''’ and only a 
brief outline need now be given. After a quick, 
temporary, right paramedian laparotomy to 
confirm operability a perineal dissection of the 
rectum is carried out with the patient in the left 
lateral position. The peritoneum is opened 
widelj' from below, first anteriorly and then 
laterally, the lateral ligaments are divided and 
the complete^' mobilized rectum is pushed up 
into the abdomen encased in a sterile glove. 
The peritoneal stitch is begun from below and 
the perineal wound is closed by suture around 
a single short drainage tube. No perineal bag or 
packing is used. 

The abdominal wound is reopened and the 
pelvic colon mobilized. The inferior mesenteric 
artery is ligated usually below the first sigmoid 
artery and the rectum and pelvic colon are 


Januaryr, ig^o 



8o 


Gabriel — Excision of Rectum 



, 6 7A 7B 

Fig. 6. Two rectosigmoid carcinomas associated with marked diverticulitis of the pelvic colon. 

Fig. 7. A, carcinoma of the rectum with two pedunculated adenomas in the pelvic colon; n, rectosigmoid carcinoma 
with a pedunculated adenoma below it and a large, sessile, villous tumor in the rectal ampulla. 



Fig. 8. A small, vascular, ampullary carcinoma with a constricting carcinoma of the pelvic colon which had 
begun to cause slight obstructive sj'mptoms. 

Fig. g. Double carcinomas of the rectum and pelvic colon; in both c,ases the upper growth was evident at laparo- . 
tomy. 


brought out through a left iliac muscle-splitting 
incision; the lateral space is closed by suture. 
The stitch closing the pelvic floor is run 
upward; this part is easy since the pelvis is 
empty. The abdominal incisions are closed 
simultaneously by the surgeon and assistant 
working together. Stainless steel wire is used 
for the anterior rectus sheath in the paramedian 


wound and for the e.\ternal oblique in the 
colostomy wound. Finally the colon is divided 
by a cautery in between Parker-Kerr forceps, 
and a soft rubber catheter is tied into the colon. 
A blood transfusion is set up as soon as the 
patient is turned on his back after the comple- 
tion of the perineal stage. The after-treatment 
follows standard lines. 

American Journal of Surgerx'' 




Gabriel — Excision of Rectum 


8i 



Fig. io. Double carcinomas, the upper growth being small and discovered 
only at the subsequent pathologic examination. (The upper carcinoma is 
marked by an arrow.) 


ADVANTAGES OF THE METHOD 

The advantages of this operation are as 
follows ; 

Time. The average time taken is between 
sixty and seventy minutes. As a rule the three 
stages are completed as follows; preliminary 
laparotomy five minutes, perineal dissection 
twenty to twenty-five minutes and abdominal 
part thirty to thirty-five minutes. Many of our 
patients are aged and frail; a quick, gently 
performed operation is an important factor 
toward a speedy recovery. 

Perineal Dissection Done Early. These pa- 
tients show little evidence of shock because the 
perineal part is done early rather than at the 
end of the operation. If a spinal anesthetic is 
given, only a small dose is required such as 0.8 
to i.o cc. of 1 in 200 nupercaine. Many patients 
with extremes of blood pressure, whether ab- 
normally high or low, are operated upon with- 
out a spinal anesthetic. They come through 
this operation perfectly well with a straight 
general anesthetic (pentothal, gas oxygen and 
a little ether or cj’’clopropane). 

Clearance of the Pelvis. A massive recto- 
sigmoid carcinoma, especially in the male, can 
always be delivered upward. This is one of the 
great advantages of the operation — the further 
it progresses the easier it becomes as the me- 
chanical difficulties are gradually surmounted. 
Figure 3 shows a massive rectosigmoid car- 
cinoma which was 12 inches in circumference 

Januarx'', ig^o 


and could not have been taken downward 
through the narrow male pelvis. Sometimes an 
additional structure has to be removed such 
as the posterior vaginal wall, a portion of 
bladder wall, the uterus or a portion of ileum. 
(Fig. 4.) All this is, I submit, easier when the 
growth is mobilized from below upward. 

Easy Closure oj the Pelvic Floor. With the 
pelvis completely empty closure of the pelvic 
peritoneum is very easily done and the cut 
edges are united in the middle line without 
tension and without artificial mobilization. No 
difficulty is presented by formed fecal masses 
in the pelvic colon above a stenosing recto- 
sigmoid carcinoma because they are exterior- 
ized with the specimen. 

Management oJ the Abnormally Short Bowel. 
A short, bulky, fat-laden rectum and the 
pelvic colon are mobilized by the perineo- 
abdominal route without special difficulty, be- 
cause the specimen is delivered upward and a 
satisfactory left iliac colostomy can always be 
established however short the pelvic mesocolon 
or however thick the fat-laden abdominal wall 
may be in a short, thick-set and obese indi- 
vidual. This type is by no means rare. Two 
different specimens are shown in Figure 5; 
they measured only 12 inches and 13 inches, 
respectively, from the anus to the iliac colon. 
This indicates the astonishing variation which 
is encountered in the length of the pelvic colon 
when realizing that in subjects of a different 



82 


Gabriel — Excision of Rectum 



I I A III) 

Fig. 1 1. Two polyposis cases; a, cnrcinonin of rectum with two large, plum- 
colored adenomas in the pelvic colon; a good example of discontinuous 
spread; n, tliis specimen exhibited four distinct carcinomas, tlie upper one 
being in the proximal part of the pelvie colon. 


build the same portion of bowel may measure 
24 to 30 inches. 

No Intraperitoneal Section oj the Colon. The 
colon is divided between clamps outside the 
abdominal wall at the conclusion of the oper- 
ation. Peritonitis from this cannot take place 
nor do the presence of fecal masses in the 
bowel add an}' extra risk. 

Colon Removed up to the Iliac Colostomy. 
The operation described enables the entire 
pelvic colon to be removed up to the left iliac 
colostomy. This is important (i) in advanced 
diverticulitids of the pelvic colon when the 
most seriously affected part of the colon can 
be removed intact and without risk of sepsis 
(Fig. 6); (2) when adenomas are present in 
conjunction with a rectal or rectosigmoid 
carcinoma; the incidence of this is usually 
about 30 per cent; sometimes the adenomas are 
above and sometimes below the main tumor 
(Fig. 7) ; (3) when two or more carcinomas are 
present, the incidence in my series being 
approximately 5 per cent. This problem of the 
double carcinoma is, to my mind, e.xtremely 
important. It recurs in certain standard forms. 
As a rule the upper carcinoma is not diagnosed 
preoperatively although sometimes it may be 
suspected when a patient with a small, non- 
obstructive ampullary growth complains of 
colicky pain with some lower abdominal dis- 


tention. (Fig. 8.) At operation the upper 
carcinoma is generally obvious as soon as the 
pelvis is examined. (Fig. 9.) Sometimes, how- 
ever, the upper carcinoma is smaller than the 
rectal growth and is only diagnosed at the sub- 
sequent pathologic examination. (Fig. 10.) The 
risk of multiple cancers is, of course, greatest 
in cases of polyposis intestini and in the 
acquired type of multiple adenomatosis. (Fig. 
II-) 

All of these situations must constantly recur 
in all surgical clinics. I submit they can be 
adequately dealt with only by a routine com- 
plete radical excision whenever an established 
carcinoma of the rectum is discovered. 

OPERATIVE MORTALITY 

The operative mortality in my series of 730 
cases is shown in Table i. Up to the age of 
forty-nine the males and females were approxi- 
mately equal in number, with a nearly similar 
mortality (7.6 per cent in men and 6.8 per cent 
in women). After the age of fifty the males out- 
numbered the females by two to one and the 
mortality in the male cases in this age group 
was 1 5.4 per cent whereas in the females it was 
7,4 per cent. The total mortality in 468 male 
cases was almost double that in 262 females 
(14 per cent compared with 7.2 per cent). 

The advantages of operating upon these 

American Journal of Surgery 


Gabriel — Excision of Rectum 


83 



I 2A I 2B ' 13 

Fig. 12. To illustrate two late C 2 cases who survived for more than five years after perineo-abdoniinal CAcision; 
A, male aged twenty-three, colloid, discontinuous spread; alive and well twelve years later; b, male aged fifty- 
four, colloid; died from bronchitis during November more than eight years later. 

Fig. 13. Venous involvement; this patient’s perineo abdominal excision was done in March, 1937; high grade 
with massive malignant invasion of the superior hemorrhoidal vein up to the level of ligation of the pedicle. He 
was sixty-two 5'ears of age at the time of operation and has survived in good health for twelve years. 


patients, when possible, in a special clinic are 
shown by my results at St. Mark’s Hospital. 
The cases here total 429. After seventeen 
deaths in the first 100 (done between 1932 and 
1938) the mortality in the remaining 329 cases 
has been twenty-one or 6.4 per cent. 

Table i 

OPERATIVE .MORTALITY AFTER ONE-STAGE PERINEO- 
ABDOMINAL EXCISION FOR CARCINOMA OF THE RECTU.M* 
MORTALITY ACCORDING TO AGE AND SEX 



Males 

Females 

Age 

1 


Per- 


1 

Per- 

Group 

No. 

Opera- 

cent- 

No. 

Opera- 

cent- 


of 

tive 

age 

of 

tive 

age 


Cases 

Deaths 

Mor- 

Cases 

Deaths 

Mor- 




tality 



tality 

20“49 

79 

6 


73 

5 

6.8 

50-85 

389 

60 


189 

14 

7-4 

Total 

468 

66 

14. 

262 

19 

7.2 


* Author’s cases, 1932 to 1948, inclusive. Total 
number 730; operative deaths 85 = 11.6 per cent. 


During the last year since using stainless 
steel wire as a routine in closing the abdominal 
wall I have had a series of eightj^-five cases 
with two deaths; this indicates a lowering of 

January' , ig^o 


mortality to 2.35 per cent. The great benefits 
conferred by stainless steel wire have long been 
recognized in America following the teaching 
of W. W. Babcock, T. E. Jones and others but 
in Great Britain we have been slow in adopting 
it. Mr. A. Lawrence Abel has been one of our 


Table ii 

FIVE-YEAR SURVIVAL RATE AFTER PERINEO-ABDOMINAL 
EXCISION OF THE RECTUM* 


Group 

No. of 
Oper- 
ative 
Sur- 
vivors 

Un- 

traced 

Died of 
Other 
Causes 
in Less 
than 
Five 
Years 

Died of 
Cancer 
in Less 
than 
Five 
Years 

i 

Alive 

at 

Five 1 
Years 

Per 

cent 

of 

Five- 

Year 

Sur- 

vivors 

A 

47 

0 

5 

5 

37 

79 

B 

108 

0 

9 

32 

67 

62 

C 

175 

0 

8 

108 

59 

33-7 

Total 

B30 

0 

22 

145 

j 

.63 

50 


* Author’s series to December, 1943. 


Staunch advocates of wire and with A. H. Hunt 
has recently published a valuable paper on its 
uses.^’ 

END RESULTS 

The five-year survival rate in my series of 
pcrineo-abdominal e.\cisions up to December, 














84 


Gabriel — Excision of Rectum 


1943, is shown in Table ii. It will be seen that 
a 100 per cent follow-up has been achieved. No 
deductions have been made for “died from 
other causes” but for the sake of clearness and 
accuracy these cases are shown in a separate 
column. Deaths within the five-year period 
from old age, urinary failure, cardiac failure, 
cerebral hemorrhage, bronchitis and pneumonia 
have accounted for a considerable number of 
deaths and have brought down the sur\dval 
rate to a lower figure than it might have been. 

By subdividing the cases into A, B and C 
groups according to Dukes’ classification the 
worsening prognosis as the cases pass from the 
B to the C groups is evident and it is perfectly 
clear that a satisfactory survival rate for 
the entire series depends on the percentage of 
A and B cases submitted to operation. With 
the high resectability rate now being achieved 
it seems likely that more than half of the cases 
submitted to operation will continue to prove 
to be C cases in which the five-year sur- 
vival rate is in the region of 35 per cent. The 
aggregate survival rate for all three groups 
combined is correspondingly reduced. In the 
present series this figure works out to a fraction 
under 50 per cent. (Table ii.) 

However, even if recurrence in the liver ulti- 
mately takes place, much relief of symptoms 
will have been experienced. That a prospect of 
cure still exists even in late C cases is shown 
by the t^vo cases depicted in Fig. 12; these were 
C 2 cases with marked lymphatic spread, and 
survival over five years took place after com- 
bined perineo-abdominal excision. 


SUMMARY 

A combined radical excision of the , rectum 
and pelvic colon is, in the author’s opinion, the 
best operation for an established rectal carci- 
noma at anj' level. 

The advantages of the perineo-abdominal 
route are set out and the results achiev'cd by 
this operation for cancer of the rectum arc 
given. 

REFERENCES 

1. OrrENiiEi.MEn, E. J. Cancer of rectum. New 

England J. Med,, 237: 1-7, 1947. 

2. Gilchrist, R. K. .mcl David, V. C. Lymphatic 

spread of carcinoma of rectum. Ann. Surg., 108: 
621-642, 1938. 

3. CoLLER, F. A., Kav, E. B. and Mac Intvre, R. S. 

Regional lymphatic metastasis of carcinoma of 
rectum. Sttrgery, 8: 294, 1940. 

4. Glover, R. P. and Waugh, J. M. The retrograde 

lymphatic spread of the “rectosigmoid region.” 
Sing., CjTicc. C'' Ohst., 82: 434, 1946. 

>. Llovd-Davies, O. V. Excision of carcinoma of the 
rectum with conservation of the sphincters (dis- 
cussion). Proc. Roy. Soc. Med., 41 : 822, 1948. 

6. Lockhart-Mummery, J. P. and Dukes, Cuth- 

DERT. Prccancerous changes in the rectum and 
colon. Surg. Cjmec. C" Obst., 46: 591-596, 1928. 

7. Binklev, G. E. and Sunderland, D. A. Diagnosis 

and treatment of papillary adenomas of rectum. 
Am. J. Surg., 75: 365-368, 1948. 

8 . SwiNTON, N. W. Diagnosis and treatment of 

mucosal polyps of rectum and colon. Am. J. 
Surg., 75: 369-373, 1948. 

9. Bacon, Harry E. and Broad, G. G. Pathogenesis 

of adenomatous polyps in relation to malignancy 
of large bowel. Rev. Gastroenterol., 15: 284, 1948. 

10. Principles and Practice of Rectal Surgery. 4th ed., 

p. 367. H. K. Lewis & Co., London, 1948. 

1 1. Abel, a. L. and Hunt, A. H. Stainless steel wire for 

closing abdominal incisions. Brit. M. J., 2: 379, 
1948. 




American Journal of Surgery 



ANORECTAL MALIGNANT MELANOMA 


Ronald W. Raven, o.b.e., f.r.c.s. 

Surgeon to The Westminster Hospital (Gordon Hospital) and to The Royal Cancer Hospital 

London, England 


M alignant melanoma is the most 
virulent of all known tumors and its 
appearance is the sign of death unless 
radical surgery is instituted in the early phase 
of its development. A study of this disease leads 
into many fields of investigation, including the 
morphology and wide distribution of dendritic 
cells, the subject of pigment formation in the 
animal kingdom, the response of melanoblasts 
in different environments including the bodies 
of hybrid animals; the development and spread 
of the disease in man and the results achieved 
by different methods of treatment. 

INCIDENCE IN ANIMALS 

Melanoma is found in many groups of 
vertebrate animals and the incidence in differ- 
ent animals is illustrated in Table i. 

In these animals the majority of the tumors 
were found in the skin; in the dog the digit and 
scrotum were affected most commonly. It is 
found frequently in grey horses; about 8o per 
cent develop the tumor in old age, chiefly near 
the anus. Brunst examined a large number of 
axolotls and discovered a male and female of 
the grey variety with minute black spots which 
later became definite melanotic tumors. Among 
the offspring of these fish similar infiltrating 
tumors were found. Myron Gordon has shown 
that spontaneous malignant melanoma is 
produced in the hybrid offspring of the black- 
spotted platyfish and the swordfish. It is 
postulated that the hybrid offspring have 
macromelanophores and micromelanophores 
whose growth habits are changed from the 
normal to the pathologic by factors in the 
swordtail acting in coniunction with the sex- 
linked dominant factor In the platyfish. 

THE MELANOBLAST 

This is the type-cell of malignant melanoma. 
In histologic preparations the cells may vary 
In shape and appear with a fusiform or cuboidal 
outline, and this has led to a classification as 
sarcomatous or carcinomatous but this differ- 
entiation is unwarranted. The melanoblast is a 

January^, IQ50 


dendritic cell which in amphibians and birds 
arises in the embryonic neural crest and it is 
assumed that in vertebrates they have the 
same origin. 

The cell is polygonal in shape with long, slen- 
der processes which are frequently branched. 


Tabie' I 

MELANOMA IN ANIMALS ROVAL VETERINARY COLLEGE, 

LONDON 


Animal 

1 

No. of 
Tumors 

No. of 
Melanoma 

Percent- 

age 

O.K 

121 

10 

8.2 

Horse 

138 

1 } 

8.0 

Dog 

1,879 

13' 

7.0 

Cat 

177 

3 

1-7 

Sheep 

17 

0 

0 

Pig 

9 

0 

0 

Total 

2.341 

155 

0. I 


The nucleus is vesicular and several nucleoli 
may be present, especially in the more malig- 
nant types of tumor. Protoplasmic fibrils are 
found running throughout the cytoplasm in the 
malignant cell but localized in the cell processes 
in the benign type. A considerable amount of 
melanin is present in some of the cells but its 
presence does not appear to affect their 
malignant properties. (Figs, i and 2.) 

There are two main types of melanoblast. 
There is a small type with very slender branch- 
ing processes which are fairly uniform and the 
melanin is localized in the periphery of the cell 
body and processes. The large type contains 
more melanin and the processes are numerous 
and much thicker with irregular swellings 
giving them a varicose appearance. Mitotic 
figures are observed frequently, and before cell 
division occurs the processes are withdrawn, 
the cell becomes globular in shape and the 
granules accumulate ,in the periphery leaving 
clear cytoplasm around the nucleus. (Figs. 3 
and 4.) 

85 



86 


Raven — Malignant Melanoma 



bryo; this is the type ceil of the melanoma. X 1 50. (Raven, R, 
\V. Proc. Rqj’. Soc. Med., reproduced by kind permission). 

Fig, 2. A mcianoblast seen under a high microscopic magnifica- 
tion in the resting phase; the middle of the cell is occupied by 
the nucleus; the cytoplasm is filled up with pigment granules. 
This is an autonomous unit, X 1,200. (Raven, H. W. Proc. Roy. 
Soc. Med,, reproduced by kind permission.) 



3 . _ 4 _ 

Fig. 3. Mcianoblast, small type, slightly pigmented and with no swellings on its dendrites; 
camera lucida dr.awing (Gkand, Chamdeus and Cameron, Am. J. Ca-ncer, reproduced by kind 
permission of authors and publishers.) , 

Fig. 4. Mcianoblast, large type, with characteristic bulbous swellings on its dendrites usually 
well developed; camera lucida drawing. (Grand, Chambers and Cameron. Am. J. Cancer, 
reproduced by kind permission of authors and publisher.) 


METASTASIZING POTENTIAL 

The malignant melanoma has a high metas- 
tasizing potential and metastases may appear 
almost simultaneously with the primary neo- 
plasm which ma3" remain very small. The 
malignant malanoblast is an individual unit 
possessing a greater degree of cell autonom3'^ 
than the cells of other tumors. It is possible 
for a single malignant mcianoblast to survive 
apart from the parent tumor and reproduce a 
new colon of cells. 

Another feature is the tendency of malignant 
melanoblasts to separate from the main tumor 
and be carried away In the blood or lymph 
streams to other localities. (Fig. 5.) The 
chances are great that this will occur and 
cytologic studies demonstrate the fact. (Fig. 6.) 
The single cell is able to pass through • the 
arger lymphatic channels and is arrested in 


the fine filtering S3’stem in the liver, lung or 
bone marrow. (Fig. 7,) When- a group of cells is 
detached, they are arrested in the regional 
i3'mph nodes. The propert3" of producing wide- 
spread metastases is an outstanding feature of 
the disease and the patient usua!i3' succumbs 
not from the primary lesion, which ma3" be a 
small nodule in the skin, but from generalized 
metastases. 


Table 11 

MALIGNANT MELANOMA — ^THE METASTATIC PICTURE 
Structures Involved 


Lymph 

! 1 

I ungs 

Liver 

Brain 

General-' 

Skeletal 

Skin 

nodes 

Heart 

1 

' 

Pancreas 

Omentum 

Bowel 

1 

1 

i 

1 

1 

! : 

[ ized i 

1 

1 

1 - 

Peivis i 

Femur 
Tibia 
Meta- 
tarsals 
Meta- 
‘ carpals 

Mul- 

tiple 

nod- 

ules 


American Journal of Surgeri' 



Raven — Malignant Melanoma 


87 



5 6 7 

Fig. 5. Cytologic study of melanoma in a dog showing an area with dividing tumor cells near the blood vessels; 
the large number of blood vessels and lymphatics in close contact with the tumor cells increases the possibility 
of widespread and distant metastases. X 700. (Raven, R. W. Proc. Roy. Soc. Med., reproduced by kind permission.) 
Fig. 6. Cytologic study of a transverse section of an artery whose lumen contains melanoblasts, leukocytes and 
erythroblasts. X 350. (Raven, R. W. Proc. Roy. Soc. Med., reproduced by kind permission.) 

Fig. 7. Cytologic study of lung at autopsy; the individual malignant melanoblasts have been separated with a 
solution of acetic acid (strength 45 per cent). The nucleoli within the nuclei of some of the cells are shown. X 700. 
(Raven, R. W. Proc. Roy. Soc. Med., reproduced by kind permission.) 


SITE DISTRIBUTION 

The lower e,\'tremity is the commonest site 
of the disease followed by the head, neck and 
face, and then the trunk of the body. The 
disease is not common in the alimentary tract. 
It may be found in the mouth arising from the 
mucous membrane of the alveolus, cheek or 
palate. Only four cases of primary malignant 
melanoma of the esophagus are reported in 
the literature and it is very rare in the stomach. 
In 1945 Herbut and Manges collected twenty- 
five cases in which the small intestine was 
affected; in nine the disease was considered 
to be primarj'^ and in sixteen secondary. 
Intussusception may be produced in this 
situation. 

The anorectal region is the commonest site 
in the alimentary canal, but the total number 
of cases reported is a little more than 100 and 
only a few are seen bj" any individual surgeon. 
Thus Ernest Miles stated he had seen three 
cases in a series of more than 1,500 cases of 
carcinoma of the rectum; and in the case 
records of the Royal Cancer Hospital over a 
period of fifteen years I could find only three 
cases. 

SITE OF ORIGIN 

The tumor arises in the skin of the anal 
canal or at the anal verge; the rectum may be 
involved bj' direct extension. (Fig. 8.) Two 
cases are reported of primary malignant mela- 
noma arising in the rectum. Thus Chalier and 
Bonnet describe a tumor occurring in the 
rectum 6 cm. from the anal orifice; and Kallet 
and Saltzstein describe the disease arising in a 
rectal pol^TD. The posterior wall of the anal 

January/', ig$o 



I 


Fig. 8 . Malignant melanoma of the anus; a lymph 
node contains a metastasis. 

canal is the usual site followed by the lateral 
walls; involvement of the anterior wall is the 
most infrequent site.. 

TYPES OF TUMOR 

A single tumor is formed usually but a 
smaller growth may be present separated by 
apparently normal tissue. In some cases there 
may be a small anal tumor with a larger one in 
the ampulla of the rectum; or the primary 
tumor may be surrounded by a number of small 
satellites. The size varies from a miliary 
nodule to a large tumor with many inter- 
mediate varieties. 

The tumor may be sessile or pedunculated. 


88 


Raven — Malignant Melanoma 



.9 . . 

Fig. 9. Cytologic study of a biopsy specimen of a melanoma in a dog showing the histologic variability of the 
tumor; the lower part of the section is ricli in melanoblasts and chromatophorcs; the cells arc long and spindle 
shaped; some are large containing cytoplasm rich in pigment. The upper part contains round cells which are 
actively dividing; few pigment cells arc present. X .too. (Raven, R. \V. Proc. Roy. Soc. Med., reproduced by kind 
permission.) 

Fig. 10. Cytologic study of tlie same tumor sliown in Figure 9 after x-irradiation witli a total tumor dose of 

2.500 r. No changes arc present and actively dividing cells arc sliown. X 700. (Raven, R. W. Proc. Roy. Soc. Med., 
reproduced by kind permission.) 

Fig. II. Cytologic study of tlie same tumor shown in Figure 9 after .\-irradiation with a total tumor dose of 

3.500 r. No favorable irradiation reaction is present. X 400. (Raven, R. W. Proc. Roy. Soc. Med., reproduced by 
kind permission.) 


It is characteristic of it to become pedunculated 
in this region and prolapse through the anal 
orifice. The base is often mobile over the deeper 
structures; the surface is lobulated and areas of 
superficial ulceration are present. The tumor 
is usually black with melanin but an amelanotic 
variety is described. Its consistency is firm and 
elastic or sometimes it feels semi-fluctuant. 

SPREAD OF THE DISEASE 

Spread by Direct Extension. There is a 
marked tendency to spread from the anal 
canal to the rectum along the submucous 
tissues. Spread also occurs laterally into the 
tissues around the anus and rectum, but this 
appears to be delayed by the fascia propia of 
the rectum. Surrounding structures, including 
the urinary bladder, uterus, vagina and 
sacrum, are not usually invaded in contra- 
distinction to the behavior of adenocarcinoma. 
Outlying nodules of tumor tissue may be 
found in the ischiorectal fossa or in the cellular 
tissues in the hollow of the sacrum. 

Lymphatic Spread. The ilio-inguinal lymph 
nodes are involved frequently; in cases in 
which one lateral wall of the anal canal is 
affected, the lymph nodes on the same side 
may be involved, those on the opposite side 
being normal. It is pointed out that a mild 


form of lymphadenitis may be present without 
involvement by metastases; it is possible this 
is a pre-invasive condition. It is necessarj’’ to 
distinguish between mclanophores and malig- 
nant melanoblasts in the lymph nodes. When 
the rectum is infiltrated, its lymphatics are also 
involved as in the case of adenocarcinoma. 
Lymph node metastases are usually black in 
color even though the primary growth is 
amelanotic. Involvement of the lymphatic 
system may be more generalized and includes 
the thoracic duct, mesenteric, mediastinal and 
cervical groups of nodes. 

Hematogenous Spread. Invasion of the blood 
vessels leads to widespread metastases, but 
sometimes their development is delayed for a 
number of years. This is especially true in 
malignant melanoma of the eye. The liver is 
involved frequently and assumes a large size 
due to the presence of nodules which maj'^ be 
black or amelanotic. The peritoneum may be 
studded with neoplastic nodules and these may 
also be present in the small intestine, great 
omentum and appendices epiploicae. The lungs 
and pleura are involved frequently and the 
subcutaneous tissues, kidney, brain and me- 
ninges, pancreas, spleen, thyroid gland and the 
skeleton are other sites for metastases to 
develop. 

American Journal of Surgery 



Raven — Malignant Melanoma 


89 


SYMPTOMATOLOGY 

A common symptom is a protruding mass 
at the anal orifice; this is dark brown or black 
and superficial ulceration may be present. This 
mass must be distinguished from a prolapsed, 
thrombosed, internal hemorrhoid. Irregular 
bowel action with frequency of defecation and 
tenesmus may be noted ; bleeding and discharge 
from the anus are frequent. When the tumor is 
situated in the anal canal, a nodular pedun- 
culated mass can be felt and a blackish dis- 
charge seen on the examining finger. 

The regional lymph nodes in the ilio- 
inguinal region may be enlarged and tender; in 
advanced cases a large mass is present and 
ulceration with suppuration may supervene. 
There may be elinical evidence of further 
spread of the disease in the abdomen and other 
parts of the body. 

When doubt exists concerning the nature of 
a swelling at the anus, a biopsy should be per- 
formed and histologic examination of the tissue 
made. 

TREATMENT 

The end results in malignant melanoma of 
this region are bad, and it is believed by some 
that the results are equally disappointing 
whatever surgical treatment is carried out. In 
spite of this despondency we believe that with 
radical surgical excision and early diagnosis 
some patients may be saved. An exploratory 
laparotomy is performed to investigate the 
extensions of the tumor; and when conditions 
are favorable, an abdominoperineal excision of 
the rectum is performed. About four weeks 
later a bilateral ilio-inguinal block dissection 
of lymph nodes is performed. 

EFFECTS OF IRRADIATION 

Cytologic studies have been made in cases 
of melanoma in man and animals. (Fig. 9.) 


The direct radiation effects on the tumor are 
minimal with the usual dosages and the in- 
tensity of the dose which is required to damage 
them is greater than the skin tolerance dose. 
No stroma reaction is present because this 
has been replaced by malignant tissue; thus 
the deleterious action of the stroma on the 
cells is lost. (Figs. 10 and ii.) These results 
indicate that irradiation should not be used 
in the treatment of malignant melanoma wdien 
surgical excision can be performed. 

REFERENCES 

Allen, V. K. Tr. Am. Proc., Soc., 32: 31, 1931. 

Bacon, H. E. and Pena, E. Clinics, 3: 457, 1944. 
CiiALiER, A. and Bonnet, P. Rev. cbir., Paris, 47: 64, 

1913- 

Chisholm, A. J. Colorado M. J., 134: 570, 1937. 
Churchman, J. W. Am. J. M. Sc., 155: 639, 1918. 
CoTCHiN, E. Personal communication. 

Dukes, C. E. and Bussey, H. J. R. Brit. J. Cancer, i : 
30, 1947. 

Gerritzen, P. Arch. klin. cbir., 178: 400, 1933-1934. 
Goldblat, M. E. j. a. M. a., 84: 1986, 1925. 
Goldman, C. and Robillard, G. L. Am. J. Surg., 57: 
352, 1942. 

Heaton, S. Tr. Path. Soc. Lond., 45: 85, 1894. 

Herbut, P. a. and Manges, W. E. Arcb. Path., 39: 22, 
1945. 

Howes, W. E. and Binnkrant, M, Am. J, Surg,, 60: 
182, 1943. 

Ingle, S. R. Indian M. Gaz., 70: 266, 1935. 

Kallet, H. I. and Saltzstein, H. C. Tr. Am. Proc. 
Soc., 33: 75, 1932. 

Kraker, D. a. Am. J. Surg., 38: 271, 1924. 

Landsman, A. A. Tr. Am. Proc. Soc., 34: 65, 1933. 
Lindner, H. H. and Wood, W. Q. Brit. J. Surg., 24: 
65, 1936-1937- 

McGuire, E. R. and Leahy, L. H. J. Bull. Buffalo 
Gen. Hosp., 2; 85, 1924. 

Marino, A. W. M. J. A. M. A., 102: 203, 1934. 

Miles, W. E. Rectal Surgery, London, 1939. 

Mirajkar, V. R. and S.achdena, Y. V. Indian J. 
Surg., 7: 50, 1944- 

Paneth. Arcb. klin. cbir., 28: 179', 1885. 

Tade, a. Sovet. kbir., 12: 81, 1935. 

De ViNALS, R. R. M. Clin. Barcelona, 2: 126, 1944. 
Virchow, R. Arcb. path. Anat., i: 470, 1847: ibid, 16: 
180, 1859. 


-• €1^ 


Janitarff^ ig^o 



EPIDERMOID CARCINOMA OF THE ANUS AND RECTUM 

REVIEW OF 125 CASES 

George E. Binkley, m.b. (Tor.) 

New ^ 'orh. New York 


E pidermoid carcinoma which occa- 
sionalB’^ occurs in the terminal intestinal 
tract is usuallj' in the region of the anus. 
This type of new growth comprises alrout 3.6 
per cent of cancers involving the anus and 
rectum. A review of 2,585 cases in which the 
cancer was situated within 18.0 cm. of the anal 
skin margin revealed 2,490 adenocarcinomas 
and ninety-five of the squamous variety. 
Epidermoid cancer occurs in both young and 
elderly adults. The average age of our patients 
was fifty-seven years, the youngest being 
twenty-seven and the oldest eighty-si.v j'cars of 
age. Females are more frequently afilicted 
than males. There were seventy-three females 
as compared to fifty-two males. A compara- 
tively high percentage of patients arc colored. 
In this series sixteen were colored and 109 
white. Venereal disease, especiallj' lympho- 
granuloma venercuhi, is often associated with 
epidermoid cancer. Thirty consecutive Frci 
tests revealed ten positive and twenty negative 
reactions. 

It would appear that the profession is un- 
familiar with many of the earlj' clinical aspects 
of this disease. The duration of symptoms 
before recognition varied from one month to 
two years. Thirty-six patients had received 
some type of treatment before coming to the 
clinic. The diagnosis of cancer in thirty-two of 
these patients had been completely overlooked. 
The mistaken diagnoses and erroneous forms of 
treatment in the thirty-two cases were as 
follows: eight had been operated upon for 
hemorrhoids; seven had received treatment 
other than surgery for hemorrhoids; ointments 
and suppositories had been prescribed for five; 
four had been operated upon for fissure and 
one for anal fistula while the remaining seven 
patients had not been informed as to diagnosis 
but had received various types of anal surgery. 

Symptoms associated with a miscellaneous 
group of patients are very numerous. Twenty- 
seven different symptoms appeared on the 
charts. Anal cancer cannot be diagnosed by 
symptoms alone. However, the early symptoms 


are usually sufficient to arouse suspicion and to 
call for examination of the anus and rectum. 
Symptoms fall into four main groups. The one 
most frequently encountered is the passage of 
blood from the anus. Blood was noted on the 
toilet tissue, on the surface of the stool or in the 
toilet bowl in ninety-one cases. The second 
most frequent symptom consisted of distress. 
The severity varied from mild discomfort to 
excruciating pain. The third important symp- 
tom involved a change in bowel habit. Fiftj"- 
fivc mentioned constipation or a decrease in the 
number of daily stools while twenty-five com- 
plained of diarrhea or frequent stools. Miscel- 
laneous complaints constitute the fourth group 
of symptoms and consist of an increased 
amount of flatus, tenesmus, feeling of a mass 
at the anus, perianal moisture, perianal Itch, 
soiling of the clothing, lack of control, cramps 
in the abdomen, loss of weight and strength, 
and other symptoms common to advanced 
malignant disease. 

Epidermoid cancer of the terminal intestinal 
tract may originate cither above or below the 
mucocutaneous line of the anus. Sites of origin 
below the line include the perianal skin and 
lower half of the anal canal. Locations above 
the mucocutaneous line arc the upper anal 
canal and the lower and upper segments of 
the rectum. 

Earlj' diagnosis is of special importance as 
the small lesions are most amenable to treat- 
ment. Early perianal lesions have the clinical 
appearance of primarj”^ skin cancers with indu- 
ration and ulceration. Two of our cases had 
been erroneously diagnosed and the patients 
were treated for ringworm. Small cancers 
situated in the lower half of the anal canal 
often appear in the form of a fissure. Thej'^ are 
most frequently located in the posterior 
quadrant. These small ulcerative lesions re- 
semble the chronic more than the acute type of 
anal fissure. They possess indurated bases 
with raised indurated edges. Occasionally, an 
acute malignant fissure is encountered. One of 
our male patients who gave a positive Frei test 

American Journal of Surgery 


90 



Binkley — Epidermoid Carcinoma 


91 


reaction had such a lesion. It was situated on a 
sentinel pile, with very little induration. 
Defecation was associated with excruciating 
pain. Epidermoid cancer may occur on the 
surface of prolapsing hemorrhoids. One of our 
elderly patients had such a lesion. It was dis- 
covered at the time of hemorrhoidectomy and 
the patient was referred for further treatment. 
Small epidermoid cancers located above the 
mucocutaneous line which involve the upper 
anal canal and segments of the rectum resemble 
closely the clinical appearance of early adeno- 
carcinomas. Both types of cancer possess 
typical cancer induration and are associated 
with congestion or ulceration. Active oozing of 
blood from such an indurated area in this 
location should always arouse the suspicion 
of the examiner as to the possibility of an 
epidermoid cancer. 

Well established epidermoid anal cancer 
should always be diagnosed by the ordinary 
rectal examination. Rectal examination when 
anal cancer is present, may require some form 
of anesthesia. Large ulcerating tumors must 
be considered malignant until proven other- 
wise. The differential diagnosis as to benign 
and malignant qualities as well as to the type 
and grade of malignancy is readily revealed by 
histologic study of a small section of tumor 
tissue. One cannot overemphasize the impor- 
tance of taking biopsies from atypical tissue 
about the anus for histologic examination and, 
also, of routinely submitting tissue removed 
at the time of anal operations. This practice is 
essential if epidermoid cancer of the anus and 
rectum is to be diagnosed in the early and most 
favorable stage. 

Anal cancer extends by continuity of tissue, 
by the lymphatic stream and occasionally by 
the blood stream. The most favorable cancers 
are the small, localized tumors without lym- 
phatic or blood dissemination. The lymphatic 
drainage of the anal canal and lower rectum is 
of special interest and may provide information 
which will prove to be extremely valuable in 
formulating treatment as well as offering an 
explanation for difficulties in removing well 
established forms of disease. We have been 
unable to find a satisfactory detailed descrip- 
tion of the lymphatic drainage of this area. 
However, after a review of the literature 
together with a revdew of the clinieal material 
it would seem that one is justified in assuming 
that the lymphatic drainage of epidermoid 

Januar^r^ 1950 


cancer of the anus is greatly influenced in the 
early stages bj" the location of the primary 
focus. Tumors located caudad to the muco- 
cutaneous line, whether situated in the perianal 
skin or in the lower anal canal, seem to drain 
chiefly into the inguinal nodes. We have 
obser\"ed, also, in two advanced cases ulcerated 
malignant nodular lesions along the lateral 
border of the scrotum. It is questionable if 
there is any lateral or upward spread from low 
lesions until the tumor has attained sufficient 
size and has extended into deeper, adjacent, 
lymphatic-drained areas. 

Epidermoid cancers located in the rectum 
•have the same Ij’^mphatic drainage as the 
adenocarcinomas of the rectum. Ljmiphatic 
drainage routes from this area have been 
emphasized by Miles. The amount of down- 
ward spread, however, seems very small unless 
the tumor is large and stenosing. It is with the 
group that is located in the rectum that the 
highest percentage of blood-stream dissemina- 
tion of epidermoid cancer occurs. There were 
five cases situated above the anus, two of 
which metastasized to the liver. The third 
group of epidermoid carcinoma is a very 
important one. Tumors in this group originate 
above the mucocutaneous line in the upper 
anal canal but usually also involve the lower 
limits of the rectum. The lymphatic drainage 
from this area appears to be very wide in 
distribution. The most active drainage is 
lateral although there is also considerable 
upward spread. Therefore, one may conclude 
that epidermoid cancer in this location may 
disseminate by the lymphatics to any of the 
following locations; (i) the levators and 
coccygeal muscles, (2) ischiorectal fossa, (3) 
rectovaginal septum, (4) base of the prostate 
and seminal vesicles and (5) along the lym- 
phatic channels of the inferior, middle and 
superior hemorrhoidal vessels. Large tumors 
involving the perianal skin or lower segment 
of the anal canal as well as the upper anal canal 
and lower rectum may be expected to dis- 
seminate not onB"^ to the above areas but also 
to the inguinal nodes. 

There is considerable difference of opinion 
as to the most effective treatment for this 
disease. One group of authors favors application, 
of radium and roentgen rays. Manj' surgeons 
consider treatment a solely surgical problem 
while others combine the application of the 
physical agents and surgical dissection. More- 



92 


Binkley — Epidermoid Carcinoma 


over, there is a good deal of difference of 
opinion as to the most effective technic for the 
three methods of treatment. There is not any 
accepted technic, for the application of roent- 
gen and radium rays. This is well illustrated by 
Roux-Berger and Ennuyer who, over a nine- 
teen-year-period of treating fifty-one patients, 
varied their treatment seventeen times. The 
method of surgical removal is not uniform 
either. A number of surgeons favor conserva- 
tive procedures such as local anal excision and 
perineal resection with or without an abdominal 
colostomy; others advocate abdominoperineal 
resections with wide perineal dissection and 
Cattell favors abdominoperineal resection with 
routine groin dissections. 

Despite the various opinions as to appro- 
priate treatment the majority of authors agree 
that the five-year results should be improved. 
Kerr reports 28.5 per cent of patients alive 
at the end of five years but all were not free 
of cancer. Keyes had 41.5 per cent of five-year 
survivals from a small series of seventeen 
patients. Gabriel had 30 per cent of cures in 
thirty cases. Roux-Berger recentlj' reported 
33 per cent of five-year cures with radiation 
therapy alone. Regardless of the type of 
treatment the results in epidermoid cancers are 
inferior to the results in adenocarcinomas of 
the rectum. 

The elTectiveness of radiation therapy in this 
disease will depend largely upon the individual 
who supervises or administers the radium or- 
roentgen rays. Each case is best considered as 
an individual problem and attention to details 
may mean the difference between success and 
failure. The extent of disease and the location 
of the tumor are two other factors which 
influence radiation therapy. The popularity 
of this form of treatment may be attributed 
largely to radiosensitivity of epidermoid cancer 
cells, a few reports of five-year survivals and 
the possibility that the patient may be freed 
of disease and still retain a normal-functioning 
anus. The most encouraging report is that of 
Roux-Berger who salvaged eighteen five-year 
cures out of a total of fifty-one patients. Seven 
of the eighteen patients required an abdominal 
colostomy while eleven had normal anal con- 
trol. Such results compare favorably with any 
type of treatment. Moreover, they indicate 
clearly that radiation therapy as a method of 
treatment is capable, if properly employed, 
of eradicating one-third of these epidermoid 
cancers of the anus and rectum. The objection- 


able features of radiation therapy are the high 
percentage of failures and postradiation reac- 
tions. Adequate dosages of roentgen and radium 
rays capable of devitalizing a large tumor are 
practically alwaj's followed by painful and 
prolonged reactions. Such reactions maj" be 
complicated by infections, tissue necrosis and 
hemorrhage. On the other hand, the reaction 
following an adequate dosage to a small anal 
cancer may be comparatively mild, especially 
if the tumor is situated below the muco- 
cutaneous line. 

The main objectionable features to radical 
surgical removal have been the frequent 
recurrences and the necessity of constructing 
an abdominal colostomy. Due to the proximity 
of the primary focus to muscle fibers it is 
impossible to do a radical removal without 
interfering with sphincter control. Radical 
rectal resections can now be performed with 
very low operative mortality, comparatively 
short convalescent periods and with a minimum 
amount of pain and distress. 

Treatment of epidermoid cancer of the anus 
and rectum has undergone a number of changes 
in the past twenty-five years in our clinic. In 
the early years treatment consisted usually 
of high voltage roentgen rays followed by the 
implantation of large amounts of radon into 
the tumor and surgical removal about seven 
to ten days after the implantation of radon. 
The type of surgical removal employed most 
frequcntlj’^ was perineal resection, with or 
without an abdominal colostomy. In recent 
j'ears cases have been selected and treated 
more in accordance with the location and size 
of the tumor and not by routine methods. 
Adequate treatment may be either conserv^a- 
tive or very radical. The majority of small 
tumors situated below the mucocutaneous line 
are treated by radiation therapy alone or 
radiation therapy followed by wide local exci- 
sion. Larger tumors in this area which appear 
to have invaded the external sphincter mus- 
cles are removed by a wide type of perineal 
resection after receiving a moderate dosage of 
high voltage roentgen ray therapy. Lymphatic 
drainage from tumors below the mucocutaneous 
line is chiefly to the inguinal nodes. We have 
not been successful in treating inguinal 
metastases by radiation therapy. Patients with 
positive inguinal nodes and those with enlarged 
nodes which are suspicious of metastatic 
disease should have wide inguinal node 
dissection. Routine prophylactic groin node 

American Journal of Surgery 


Binkley — Epidermoid Carcinoma 


93 


dissections have not been employed in this type 
of case. 

Small epidermoid cancers situated above the 
mucocutaneous line in the upper anal canal 
and lower rectum usually disseminate in 
lateral and upward directions. They are less 
accessible for adequate radiation therapy 
than those situated below the line. Moreover, 
it is difficult at times to estimate the exact 
extent of cancer infdtration into the adjacent 
tissues. Experience suggests that this group is 
more difficult to eradicate by radiation therapy 
than those situated in a lower location. The 
percentages of incomplete eradication after 
radiation therapy have been rather high. Our 
present day method of treatment for tumors 
above the mucocutaneous line consists of 
preoperative high voltage roentgen rays and a 
wide, one-stage abdominoperineal resection. 

Large tumors and more extensive forms of 
disease receive preoperative high voltage 
roentgen ray therapy and a very radical 
abdominoperineal resection. The dissection in 
most cases is carried far beyond that described 
by Miles. In the female the uterus and a part 
or the whole vaginal tube are often removed. 
In the male the dissection may include the 
removal of the seminal vesicles or a section of 
the prostate. Wide excision of the perianal 
skin, muscles, fat and lymph-bearing tissue 
within the pelvis is advocated in all cases. 
Radical inguinal node dissection is necessary 
with positive and suspicious inguinal metas- 
tasis. The inguinal dissection is carried out 
seven to ten days after abdominoperineal 
resection. Routine prophylactic groin node 
dissections have not been employed. In the 
future, however, routine groin node dissections 
may prove necessary when dealing with exten- 
sive low-lying cancers. Several cases are 
reported in the literature of inguinal metastases 
developing years after the primary focus had 
been removed. One of our patients who was 
treated by radiation therapy developed groin 
node metastases after being free of disease for 
seven years. Careful follow-up examinations of 
larger series of cases when advanced disease 
involves the lower anal canal and perianal skin, 
will help greatly to clarify the problem of 
inguinal node dissections. 

The advanced inoperable group is treated 
chiefly by high voltage roentgen ray therapy. 
The raj's are administered through seven or 
more pelvic portals. In the beginning sufficient 
dosage is given to reduce the symptoms. Sub- 

January, ig^o 


sequent applications are given usually after an 
interval of two to three months in accordance 
with the progress of the case. An abdominal 
colostomy will occasionally be necessary for the 
inoperable patient in order to prevent the 
passage of stool through a rectovaginal fistula 
or over a very painful anal canal. 

A review of 125 histories revealed that 
ninety-three patients came to the clinic prior 
to 1944 or more than five years ago. Ten of 
these patients received the major part of their 
treatment, either surgery or irradiation, at 
other institutions before or after being admitted 
to our clinic. Four patients refused surgery and 
were treated along palliative lines. Of the 
remaining seventy-nine patients sLxty-five were 
operable and fourteen were considered in- 
operable. Of the sixty-five operable cases there 
were two postoperative deaths. Five were lost 
to follow-up. Of the remaining fifty-eight cases 
twenty-seven survived five years but two were 
not considered to be free of disease at the end 
of that interval. These figures reveal a five-year 
survival of 29 per cent from the total group or 
a 41 per cent survival for the operable cases. 
It is believed that with selective treatment, in 
accordance with the size of the primary focus, 
the location and the possible lymphatic dis- 
semination, the future results of epidermoid 
cancer of the anus and rectum will show 
marked improvement. 

REFERENCES 

1. Buie, L. A. and Brust, J. C. M. Malignant anal 

lesions of epithelial origin. Journal Lancet, 53: 
565-571, 1933. 

2. Cattell, R. B. and Williams, A. C. Epidermoid 

cancer of the anus and rectum. Arch. Surg., 46: 
336-349. 1943- 

3. Gabriel, W. B. Squamous-cell carcinoma of anus 

and anal cancer. Proc. Roy. Soc. Med., 34: 139-157, 
1941. 

4. Kerr, J. G. Squamous-celled carcinoma of the anal 

and rectal regions. Texas State J. Med., 36: 546- 
555, 1940. 

5. Keyes, E. L. Squamous cell carcinoma of the anus 

and rectum. S. Clin. North America, 24; 1151- 
n6i, 1944. 

6. Miles, W. H. Pathology of spread of cancer of 

rectum, and its bearing upon surgery of cancerous 
rectum. Surg., Gynec. *• Obst., 52: 350-359, 1931. 

7. Raiford, T. S. Epithcliomata of the lower rectum 

and anus. Surg., G^mec. & Obst., 57: 21-35, >933' 

8. Roux-Berger, j. L. and En.n’ui'er, A. Carcinoma 

of the anal canal. Am. J. Roentgenol., 60: 807-815, 
1948. 



94 


Binkley — Epidermoid Carcinoma 


DISCUSSION OF PAPERS BY DRS. DUKES, GABRIEL, 
MAYO, RAVEN AND BINKLEY 


T. E. Jones' (Cleveland, 0 .): I shall limit my 
remarks ehiefly to survival rates. JJowevcr, I must 
pause to state that this is probably the finest 
symposium on the subjeet that this organization 
has ever had. My position on the operative treat- 
ment for carcinoma of the rectum is so well known 
to you that there is no use reiterating it. In defense 
of this radical procedure I wish to report on the 
survival rate of 102 consecutive patients operated 
on in 1938 and 1939. 

The specimens removed were e.vamincd thor- 
oughly after the method of Dukes, Coller, David 
and Gilchrist. This gave us considerable informa- 
tion regarding lymphatic and venous spread which 
have a bearing on survival rates. For instance, the 
smallest lesion, 2.5 cm. in diameter, had 14 per 
cent involvement in the glands removed while the 
largest, 71 cm. in diameter, had no glands involved; 
so who are we to say that we can project a certain 
type of limited operation for a lesion of a certain 
size or location. From my experience radical 
operation is nccessarj^ if we arc to have a respect- 
able survival rate and, that not being possible, to 
make patients more comfortable by limiting local 
recurrence to a minimum. 

What we are interested in now in the controversy 
between one operation or the other, it seems to me, 
is the survival rate. The more of these that we get 
into the literature that are accurate, the better off 
we shall be in trying to find out maybe in five or 
ten years just where we stand. 

Twenty-five years ago it was very difficult, of 
course, to put this operation over because of the 
objection to the high mortality; it was 20 to 30 per 
cent. As you know, over the intervening years this 
has come down to a mortality now that is almost 
as low as that of acute appendicitis, even with all 
the antibiotics. 

From 1940 to 1947 we did 802 operations with a 
mortality of 24 or 3 per cent. The entire group is 
nearly 1,300 now and the over-all mortality is 5 
per cent in the entire scries. 

In 1937 it was my privilege to visit Dr. Dukes at 
which time he showed me everything that he was 
doing. When I came home I decided that I would 
take 100 consecutive cases and do everything that 
he did, put those cases on the shelf for ten years 
and then find out just exactly what happened to 
them. As a sample of operability we may say that 
in ten months of 1947 of 105 patients sent to the 
hospital as candidates for the operation, eighty- 
eight operations were completed, a resectability 
rate of 87 per cent. Of course, there are many cases 
that one has to turn down in the office because of 
obvious metastasis. 


W 


We did 102 consecutive cases in. 19^8 to 1940. 
e now have a complete follow-up on ninety-six 


of these cases. We know exactly what happened to 
10 1 of the 102 cases, practically a 100 per cent 
follow-up. Me also informed me that it made no 
material difference in the statistics because two 
patients were alive and three were dead. The oldest 
in this group was seventy-two years of age and the 
youngest twcnty-sev'cn; the average age was 52.9. 
We included four patients who had liver metastasis 
at the time of operation. If you begin to throw out 
cases, you would have 100 per cent results in 
everything, so we included all of these cases when 
computing the survival rate. 

We have not grouped the cases according to A, 
B and C as does Dr. Dukes. I think it would be a 
marvellous idea if everybody would do that. We 
arbitrarily divided them as to number of glands 
in%'olvcd, o to 5 and over 5. In the o to 5 group of 
cases there were scvcntj'-cight. In the five-year 
survival rate of seventj'-three patients, forty-four 
arc alive or practically 60 per cent; eight years, 
forty-one of seventy, or 58 per cent; nine years, 
thirty-three of fifty-nine or about 52 per cent; ten 
years, fourteen of twenty-eight arc alive or 50 per 
cent. The aforementioned is a group of cases that 
had cither none or under five glands involved. This 
is pointed out particularly to show again the value 
of early diagnosis. 

In the group that had five or more glands in- 
volved there were twenty-four cases. One can see 
immedi.atclj'- the terrific drop in the survival rate: 
In the five-year survival rate five of twenty-two 
arc alive, a percentage drop from 60 to about 
22 per cent. 

That I believe would correspond quite closely 
with what Mr. Gabriel reported that 18 per cent of 
the pafients remained alive. I think probablj' this 
group of patients with five or more glands involved 
would correspond to Group C; eight years, four of 
twenty-two are alive; nine years, four of eighteen 
or 20 per cent; ten years, one of nine. 

It proves again that if the case goes on for about 
five years, the chances of the patient not dying of 
cancer arc very good. We considered everybody as 
having died from cancer. Many of these patients, 
of course, died of old age because many of them 
were over sixty at the time of operation and in ten 
years might have died of anything. 

We know that many doctors in the follow-up 
would say, “Old John Jones died of pneumonia.” 
You and I know that as likely as anything the 
chances are that the man had a pulmonary metas- 
tasis. We wanted to find out how many patients 
were alive and how many were dead regardless of 
deductions for questionable cause of death. 

Ninety-two of the 102 cases were without venous 
involvement. In eight years 50 per cent were alive; 
nine years, 50 per cent; ten years, about 47 per 
cent. This again shows that the ratio between the 
five- and the ten-year cures is quite static. 

American Journal of Surgery 



Binkley — Epidermoid Carcinoma 


With ten cases of venous involvement in five 
years we had three patients alive of ten or 33 per 
eent. There again you see a drop of from 60 to 33 
per cent, depending upon the extent of the case. In 
eight years three of the ten patients were still alive; 
one of three, nine years. 

The following is the over-all survival rate not 
considered as to any kind of group, bad, good or 
indifferent: fifty-one patients or 52 per cent were 
alive at the end of five years; eight years, 48 per 
cent; nine years, 49 per cent; and ten years, a very 
satisfactory rate when every death is considered 
as being due to cancer, we have a survival rate of 
43 per cent. 

The only thing that I want to say in defense of 
this procedure is: If this is the best we can do with 
the most radical operation that can possibly be 
done, what is the use of considering smaller 
operations? 

Neil W. Swinton (Boston, Mass.): At the clinic 
we have been very conservative in regard to 
performing anterior resections for carcinoma of the 
rectum. We have performed a small number of 
reseetions for lesions 14 to 16 cm. above the anal 
margin but by far the majority of malignant lesions 
of the rectum and lower sigmoid has been removed 
by abdominoperineal resection in one stage. 

As to end results, we have followed Dr. Dukes’ 
classification. Our cases are classified as to whether 
or not they have a blood vessel and glandular 
involvement. 

Last year Dr. Lahey reported a series of 18,000 
cases of carcinoma of the rectum in which go per 
cent of the patients have survived five years who 
did not have either lymph gland or blood vessel 
invasions. Cases with regional lymph node involve- 
ment but without blood vessel invasion showed a 
five-year survival rate of 37 per cent; when blood 
vessel invasion was encountered that number 
dropped to 14 per cent. These figures are in general 
agreement with what has already been reported 
here. 

CuTHBERT Dukes (closing): It. has been sug- 
gested by one distinguished surgeon that I might 
perhaps play the part of an undertaker. I recollect 
it was one of your great American humorists, Mark 
Twain 1 believe, who said that he spent his life 
trying to avoid being overtaken bj' an undertaker. 

I do not want to be the undertaker. But if I 
could play a role, I wish that I might be created a 
midwife. Do you understand what a midwife is? 
Is it the same in America? They tell me the word is 
obstetrician. 


95 

I would like to see something new born: a new 
organization which would make it possible for- us 
to come together more closely and to pool our 
experience in the future. 

C. W. Mayo (closing).: Having been fairly com- 
pletely and firmlj’- castigated, I do think that I 
must make just a few additional remarks. 

First, I should like to describe the conditions 
under which I do the so-called low anterior seg- 
mental resection. I perform the abdominal portion 
of the operation exactly the same as I do the com- 
bined abdominoperineal resection. After removal 
of the specimen (and I do not decide until after its 
removal whether or not I will do that type of 
resection) I immediately have the specimen opened 
and brought to me in the operating room. If I see 
that it has been possible to cut the bowel and 
mesentery at least 2 cm. below the lower border 
of the growth, I start the resection. Then the 
pathologist returns and tells me whether or not 
lymph glands are involved. If glands are involved, 
sometimes I go ahead; but if the pathologist tells 
me that I should carry out a one-stage combined 
abdominoperineal resection, I do so. 

The anastomosis between the sigmoid and rec- 
tum never must be made under tension. If neces- 
sary, the bowel can be loosened along the lateral 
peritoneal fold of the sigmoid and descending 
colon. Also, it must be possible for the surgeon to 
make an accurate anastomosis. If these two things 
are possible, I believe the operation is a good one. 
If they are not possible, a one-stage combined 
abdominoperineal resection should be performed. 

If I had a carcinoma situated, say, within 6 cm.' 
of the dentate margin, I would just as soon have 
Tom Jones, Mr. Gabriel, Mr. Abel, Mr. Morgan or 
any one of a number of others do a one-stage 
combined abdominoperineal resection or a perinco- 
abdominal resection. If, however, I had a carcinoma 
that was situated more than 6 cm. from the dentate 
margin, I doubt that I would let them operate on 
me with the feeling they have although I will not 
include all of them — I will not include Mr. Morgan. 

I think I would be very careful because I would like 
to have someone operate upon me who is more 
impressed with the need for preservation of the 
anus than thej"^ evidently are. 

On the other hand, however, should they be so 
unfortunate as to have a lesion situated 7, 8, 9 or 
10 cm. above the dentate margin and if they should 
wish me to do a combined abdominoperineal 
resection, I would be very happy to do it and give 
them an abdominal colostomy. 


€ 1 ^ 


January, ig^o 



SPREADING ULCERATION OF THE SKIN ASSOCIATED 
WITH IDIOPATHIC ULCERATIVE COLITIS 

E. C. B. Butler, f.r.c.s. 

London, England 


P ROGRESSIVE ulceration of the skin is 
a rare but important complication of 
ulcerative eolitis. In the United States 
Jankelson and McClure (1940) reported seven 
cases, citing twelve others from the literature 
and Felson (1941) described three cases. Jankcl- 
son and McClure thought the condition was due 
to a vitamin deficiencj' while Felson ascribed it 
to an impaired resistance to infection. Until 
last year no British reference could be found. 
In the last 100 patients with this disease ad- 
mitted to the London Hospital four cases of 
progressive ulceration have been found, three 
severe and one trivial. None of these patients 
has died. 

CASE REPORTS 

Case i. A married woman, aged thirty, was 
admitted on August 8, 1942, to the London Hos- 
pital with the following history: Her first attaek of 
uleerative eolitis, proved by sigmoidoseopy, oc- 
curred in 1934. In 1938 she had a further attack 
lasting for some months. She had remained well 
until six weeks before admission. Since then she 
had suffered from severe diarrhea and rectal 
bleeding. 

On admission there were no unusual signs. The 
stools contained blood and pus. No pathogenic 
organisms were isolated. September i, 1942, she 
complained of a small, raised, painful swelling on 
the left shin. Five days later a blood transfusion 
was given in the left arm by cutting down on the 
vein. Soon after an ulcer formed at the transfusion 
site. September 9, 1942, the swelling on the leg 
broke down to forrn an ulcer which spread very 
rapidly. Although the discharge from the ulcer was 
profuse and purulent, repeated cultures remained 
sterile for some days. After this secondary infection 
occurred. Many organisms were then cultured from 
the ulcer. Staphylococcus aureus predominated. 

The base of 'the ulcer was composed of pus and 
sloughs but the Infective process did not go beyond 
the deep fascia. The edge was raised, red, ex- 
quisitely tender and undermined. The skin sur- 
rounding the ulcer was red and indurated to a 
breadth of inch. Spread of the infection occurred 
in a very characteristic manner. 

The raised, undermined edge rapidly dissolved 

96 


into pus leaving a fresh, red area which in turn soon 
became undermined and necrotic. 

A similar ulcer also formed on the left arm at 
the site of her first blood transfusion. The pain was 
so intense that the patient screamed whenever the 
dressings were changed or the affected limbs 
moved. 

Local therapy consisted of hypertonic saline 
dressings, local sulfonamides and ultraviolet light. 
General measures included repeated blood trans- 
fusions, oral sulfonamides and a low-residue, 
high-vitamin diet. In giving further transfusions 
care was taken not to cut down on a vein. 

The ulcers continued to spread until by October 
14th all the skin of the patient’s leg had been de- 
stroyed from just below the knee to the level of the 
ankle. A similar ulcer on the patient’s arm involved 
two-thirds of the forearm. The patient was 
critically ill. On October 1 5th the red growing edge 
of both ulcers was completely excised with a 
diathermy knife. Only the skin and superficial fat 
were involved. The pathologic report showed 
pyogenic infection. The next daj”^ the pain had 
disappeared. The edge of the ulcers remained clean 
and clear cut; there was no circumferential redden- 
ing of the skin. The disciiargc appreciably di- 
minished and soon fresh cpitlielium started to grow 
in from the periphery. 

Local treatment after operation consisted of the 
repeated application of sulfathiazole powder. 
Whereas before operation local chemotherapy 
seemed inefficient, postoperative treatment was 
successful. Possibly the preoperative failure was 
due to the excessive discharge which rapidly 
rendered the sulfonamides inactive. 

On October 19th an enormous rectal hemorrhage 
occurred; the pulse rate rose to 1 58. Five pints of 
blood were given. After this relapse secondary 
infection of the muscles of the arm occurred. On 
December 12th the left arm was amputated; 2 more 
pints of blood were given during the operation. 
The wound healed by first intention. No further 
spread of infection occurred in the leg. Rectal 
bleeding stopped. In February, 1943, she went 
home; her weight was rising, the ulcer was clean 
and her bowels were open twice daily and con- 
tained no blood. 

In October, 1944, the leg was grafted by Mr. 
Rainsford Mowlem, with an excellent result. In 
October, 1945, the patient was readmitted to the 

American Journal of Surgery 



Butler — Ulceration of the Skin 


97 


London Hospital for delivery of a full term child. 
While in hospital her leg remained healed although 
there were some further diarrhea and hemorrhage 
from the rectum. Her general health is now 
excellent. 

Case ii. A woman, aged forty, was admitted on 
November ii, 1944, with bilateral painful ulcera- 
tion of the legs. She stated that her colitis began 
in 1939 and in 1941 she had a transverse colostomy 
followed by a terminal ileostomy in 1942. In 1943 
Mr. Hermon Taylor performed a partial colectomy; 
the ascending colon and part of the transverse 
colon were not removed. 

On admission her condition was good. She had 
an irregular pyrexia; the discharge from her colon 
had increased lately and consisted of blood and 
pus. On both legs there were large ulcers with 
raised red tender undermined edges. The bases 
were composed of pus and sloughs. Bacillus proteus 
and hemolytic streptococcus were obtained from 
cultures at various times. Her treatment consisted 
of a high-vitamin, low-residue diet. Systemic 
penicillin, 120,000 units daily, was given for a 
week; penicillin powder was applied locally. During 
this time her condition deteriorated and the ulcers 
doubled their size. On December 3rd the edge of 
both ulcers was excised with a diathermy knife; 
oozing was checked by elevation of the legs dur- 
ing and after operation. Another blood trans- 
fusion was given. Postoperatively penicillin sulfon- 
amide powder was applied locally. The remains of 
the colon were irrigated daily with a suspension of 
succinyl sulfathiazole. The ulcers stopped spreading 
and the discharge from the colon practically ceased. 

In January the patient was transferred to the 
care of Mr. Hermon Taylor. During the next 
month further discharge from the colon took place 
and the ulcers again became painful with renewed 
spread. In March Mr. Taylor excised the remainder 
of the colon. Pathologic report revealed infection 
of the colon with chronic inflammation of the 
lymphatic nodes. 

After the operation the patient’s general condi- 
tion rapidly improved. The ulcers ceased to spread 
and gradually healed; skin grafts were not required. 
In April, 1945, she was sent home and has remained 
well ever since. 

Case hi. A male, aged eighteen, was admitted 
with a two-year history of rectal bleeding, pyrexia 
and loss of weight. Examination showed a wasted 
lad with irregular pyrexia. Sigmoidoscopy showed 
typical ulcerative colitis with the beginning of 
polyposis. 

His condition improved somewhat with medical 
treatment and blood transfusions but an intractable 
stricture of the rectum developed. On March 27, 
1945, a terminal ileostomy was performed. Follow- 
ing operation the patient’s condition improved; 
his pyrexia settled and his weight rose rapidly. 

January 24,- 1947, he was readmitted with a four- 

January, ig§o 


month history of ulcers on his legs. On examination 
his general condition was good and he had been 
able to go to work. The ileostomy functioned 
satisfactorily. There were small painful ulcers on 
_ both legs below the knee. Culture showed B. 
proteus. 

With rest in bed and local chemotherapy the 
ulcers rapidly healed. Since then they have recurred 
on one occasion. It is probable that the patient will 
be admitted before long for a colectomy. 

Case iv. A woman, aged twenty-four, for two 
and a half years had suffered from diarrhea with 
the passage of blood and mucus per rectum. For 
one year the symptoms had become worse and 
ulcers had developed in her mouth. Seven months 
previously spreading ulcers of the face and external 
genitals had developed. She was admitted to the 
hospital and treated with blood transfusions and 
systemic and local chemotherapy. She also was 
given a course of x-ray therapy. Sigmoidoscopy at 
that time showed ulcerative colitis. With this treat- 
ment her colitis gradually improved and the ulcer 
on her vulva cleared up. 

On April i, 1947, she was admitted to the London 
Hospital. Her general condition was good and 
sigmoidoscopy showed atrophic mucosa but no 
active ulceration. Her face was considerably 
deformed by the presence of multiple ulcers with 
shallow edges and necrotic bases. Culture from 
these ulcers showed many organisms, most of them 
gram-negative. 

Various local drugs were tried on her face without 
success and the lesions got progressively more 
painful as time went on. May 20, 1947, the ulcer 
on the left temple was excised and a split skin graft 
applied. The graft partly broke down but later 
healed completely. July 22, 1947, the ulcer on the 
right cheek was excised and grafted. On August 1 5, 
1947, the face had healed, the colitis was quiescent 
and the patient was transferred home. 

COMMENTS 

In three of our cases the skin ulceration was 
severe. However, it is evident from the litera- 
ture that all grades of skin involvement may 
occur in association with ulcerative colitis, as in 
Case III in which the ulcers were not painful 
and healing rapidly occurred with rest and 
chemotherapy. 

In this paper, however, we are chiefly con- 
cerned with the severe skin lesions since their 
clinical picture is unmistakable and because 
they may be a danger to life. 

The ulceration seems to occur in patients who 
have suffered from colitis for some time: In 
our severe cases and in others reported else- 
where the skin ulceration began during an 
exacerbation of the colitis as showm by pyrexia. 



98 


Butler — Ulceration of the Skin 


diarrhea and rectal bleeding. We also noted 
that healing of the ulcers appeared to depend 
on the cessation of the active phase of the 
colitis, in one case following medical treatment 
and in the other after colectomj\ It was noted' 
in the second case that a relapse of the colitis 
was accompanied by a further e.\acerbation of 
the skin ulceration. 

These facts suggest that the skin lesions are 
clearly linked with colitis but in what waj' is 
uncertain at present. It is possible that several 
factors play a part. First, there may , be a de- 
ficiency due to lack of biosj'nthesis of certain 
vitamins in the diseased bowel. Secondly, the 
original skin lesion maj^ be an allergic phenom- 
enon similar to that which originally may have 
caused the colitis. This view is supported by 
the fact that in one of our cases the discharge 
from the ulcer was sterile for several days which 
was against a diagnosis of primarj’ bacterial 
infection. Thirdly, lowered resistance of the 
patient to infection coupled with sccondarj' 
anemia undoubtedly promotes the incidence of 
sever secondary infection which so often occurs 
in these cases. 

In our first case cultures from the lesion were 
sterile for some days before pyogenic infection 
occurred. The other cases were not admitted to 
the hospital until secondary infection was well 
established. Cultures from our cases showed at 
various times staphylococci, hemolytic strepto- 
cocci, B. proteus and B. pyocj^aneus. 

The lesion begins as a raised, red papule 
which rapidly breaks down to form a small 
ulcer. In mild cases no further spread may occur 
but in others the discharge becomes profuse and 
the ulcer rapidly increases in size. Severe pain 
is then a characteristic feature. The most com- 
mon sites appear to be the limbs but any part 
of the body may be affected. Unless the condi- 
tion is checked, the ulcer may spread until the 
patient is in danger of dying from toxemia and 
anemia. Spontaneous arrest may take place if 
there is a clinical improvement in the colitis but 
in severe cases energetic local and general treat- 
ment is required to halt the spread of the 
ulceration. 

When the infective process has been healed, 
epithelium-rapidly grows in from the edge of 
the ulcer; but skin grafts may be required when 
the lesion has been extensive. 

Severe cases of ulceration must be treated 
vigorously; our first patient nearly died because 
the diagnosis was not made early enough. 


If the colitis is in- an acute stage (Case i), 
medical treatmeh't Vvill probably suffice. The 
diet should have a high protein, low residue con- 
tent, and plenty of essential vitamins. Oral 
sulfonamides and systemic penicillin should be 
given but in our two worst cases the results 
from chemotherapy were disappointing. It is 
possible that larger amounts of penicillin (up to 
approximately one million units a day) might 
have had a more favorable result in Case ii. 
Repeated blood transfusions are essential to 
combat the secondary' anemia. 

If the patient docs not improve, ileostomy 
should be considered. In more chronic cases 
(Case ii) surgical treatment may be required 
more frequentlj' since the skin lesions may re- 
lapse with each exacerbation of the colitis. 
Ileostomy maj" be required and colectomy is 
often advisable. Locallj’’ we found that the 
treatment which appeared to stop the spread of 
the ulceration was c.\cision of the whole of the 
edge with a diathermy knife. The result was 
dramatic pain vanished, the edge of. the ulcer 
became clean and clear cut, and the response to 
local chemotherapy was good. 

At operation the limbs should be raised to 
avoid the considerable blood loss from venous 
oozing. These patients do not tolerate loss of 
blood and every effort should be made to pre- 
vent undue hemorrhage. A blood transfusion is 
advisable during operation. Excision with an 
ordinary knife might be equallj' satisfactory 
but the diathermy appeared useful in prevent- 
ing blood loss. Complete excision of the affected 
area (Case iv) followed bj' immediate skin 
grafting may be successful provided that the 
general condition of the patient is good at the 
time of operation. 

Postoperative therapy consists of repeated 
application of penicillin sulfonamide powder 
with early skin grafting if this is required. 

Acknowledgment. My thanks are due to the 
Editors of the Proceedings of the Royal Society of 
Medicine for allowing me to republish the case 
reports of three of the aforementioned patients. 

REFERENCES 

1. Felsen, J. Multiple necrotizing skin lesions in 

chronic ulcerative colitis. New York State J. Med., 
41 : 2228-2231, 1941. 

2. Jankei-SON, I. R. and McClure, C. W. Skin lesions 

during course of ulcerative colitis. Acta dermal.- 
aenerco/., 21: 255-267, 1940. 

Dr. Thorlaksson (Winnipeg, Canada): We are 
indebted to Mr. Butler for his review of four cases 

American Journal of Surgery 



Butler — Ulceration of the Skin 


99 


ilfustrating the -very rare but a very distressing 
complication of.ulcerative colitis. It is significant, I 
believe, that the early cultures taken from these 
lesions were sterile. One is tempted to speculate as 
to the possibility that this cutaneous manifestation 
is not really a counterpart of what has already 
taken place in the colon in a susceptible individual. 
But I am aware that such an observation leads one 
into the discussion of the etiology of ulcerative 
colitis, a subject that 1 approached very boldly 
before this Society twenty years ago at a meeting 
in Detroit, Michigan. However, I would retire 
from such a controversy as gracefully as possible. 

There are several very interesting clinical prob- 
lems presented by these cases. It is true that 
ulcerative colitis is rare, yet probably not as rare 
as the reported cases would indicate. 

In the last sixty cases of chronic ulcerative colitis 
that I have observed there were quite a few in- 
stances of gangrenosum keratosis. In the last case 
the lesion extended from the forehead almost to the 
ankle involving all extremities, the trunk and neck, 
the face and the forehead, in patches, of course. In 
this patient the condition was associated with 
jaundice; the patient was critically ill. As Mr. 
Butler has so well emphasized, these patients 
require active supportive treatment with repeated 
blood transfusions, a high-nutrition diet and a 
great deal of encouragement. He referred to the 
effect of the antibiotics. I will not go into detail 
with the clinical history of the case, but the last 
case was a young man of twenty. He had ulcerative 
colitis for five years. It is significant that three 
years earlier he had had an ileostomy performed, 
as in one of Mr. Butler’s cases. In spite of the 
ileostomy he had retrogression of his ulcerative 
colitis in its most acute form with these diffuse 
ulcerative lesions of the skin. However, with sup- 
portive treatment he improved. 

While he had responded during previous attacks 
treated elsewhere with penicillin, it was our impres- 
sion that streptomycin was more effective not in 
preventing the original lesion, of course, but in 
controlling or helping to control the secondary 
infection that supervenes. 

It is my understanding, at least on the basis of a 
small series of cases, that the only cure for this 
condition is a total colectomy. It is one of the 
definite indications for colectomy and we must 
put it beside the positive proof of carcinoma, mul- 
tiple stricture, persistent fever, anemia and an 
otherwise intractable case that does not respond 
to medical treatment. I believe that this condition 
which has been so well described by Mr. Butler is 
a definite indication for colectomy. 

For me the meeting has been most stimulating. 
As a Canadian I would like to say that it is on 
occasions of this kind that we in Canada are par- 
ticularly proud of our British and American 
affiliations and friendships. 

Januarx'', ig$o 


Garnet W. Ault (Washington, D.C.): In our 
experience with 138 cases of chronic ulcerative 
colitis we believe that an incidence of possibly 3 or 
4 per cent of pyoderma gangrenosa will occur. It 
is, of course, obvious to all who deal with this 
disease that while caring for the first fifty patients 
you are a great enthusiast; the next few cases you 
begin to wonder if enthusiasm is the correct word 
and after a few more cases you become verj’ 
humble. Ulcerative colitis is much more difficult to 
treat surgically than is malignancy. 

In discussing Mr. Butler’s cases it is to be noted 
that these patients had their disease for eight 
years, for five years, and two patients for two and 
a half years, respectively. Therefore, the im- 
ponderable factors of vitamin deficiency, malnutri- 
tion, secondary infection, allergic phenomena and 
so forth are to be evaluated for each individual. 

However, the specific sequence of events in the 
development of pyoderma gangrenosa should be 
emphasized. These lesions nearly all begin as a 
small, red papule which becomes a tender, red 
ulcer with induration in the skin and subcutaneous 
tissues for a distance of 14 inch or more. Dissolution 
and slough occurs and pain is a predominant 
symptom. It is to be noted that the development 
of pyoderma gangrenosa is related to the decline 
of the patient; it is usually not relieved by an 
ileostomy but is definitely improved by colectomy. 

I am not aware of any patient developing pyo- 
derma gangrenosa after removal of the eolon. 

The illustrations in Mr. Butler’s article show 
that pyoderma gangrenosa can extend beyond the 
stage of simple ulceration. The extensive ulceration 
of the leg demonstrating an erythematous border, 
a necrotic edge and finally the large ulcer area has 
the appearance of bacterial synergistic gangrene as 
described by Dr. Frank Mclency of New York in 
1926. The patient whose faee shows the chronic, 
undermining burrowing with scarring probably has 
a different type of infection. 

Ulceration of the skin and subcutaneous tissues 
that develops in patients who have ulcerative 
colitis can be very serious. An inefficient blood 
supply resulting from capillary thrombosis will 
produce a sloughing ulcer. Infection by pathogenic 
organisms develops. Therefore, it is necessary for 
us to be bacteriologically minded or even amateur 
bacteriologists. If possible, we must identify by 
culture the organisms that are responsible for these 
sloughing ulcerations. Four types of ulceration 
should be considered as follows: 

Hemolytic streptococcus gangrene is an acute 
process. The lesion develops with marked redness, 
peripheral edema and blister formation. Necrosis 
of the skin and subcutaneous tissues ordinarily 
develops between the seventh and tenth days and 
open ulceration follows: A hemolytic gram-positive 
streptococcus may be isolated in pure culture deep 
in the peripheral zone of spread. Prompt surgical 



100 


Butler — Ulceration of the Skin 


incision is indicated and large doses of bacitracin 
and penicillin arc recommended. 

Chronic, progressive, postoperative, synergistic 
gangrene is an indolent, progressive type of ulcer- 
ation. The lesion develops over a period of seven 
to fourteen days as a red, tender area which soon 
turns purple and becomes gangrenous. Exquisite 
tenderness and pain are noteworthy. A micro- 
acrophilic non-hcmolytic streptococcus may be 
isolated by anaerobic methods from the deep 
peripheral zone of spread and a gram-positive 
hemolytic staphylococcus aureus may be recovered 
from the area of open ulceration. Surgical c.xcision 
beyond the zone of erythema is indicated and the 
use of bacitracin is recommended. 

Amebic ulceration is an indolent, progressive 
ulceration that may develop around the buttocks, 
at or near the anus, around a colostomy or intes- 
tinal fistula or at the site of drainage of a liver 
abscess. Secondary infection is usually associated 
with the ulcerative process. The response to 
emetine and other amcbecidal drugs is limited so 
that excision followed by grafting is often necessary. 

Undermining, burrowing ulcer is a slow, progres- 
sive, destructive ulceration due to a gram-positive 


micro-aerophilic hemolytic streptococcus. It is 
characterized by burrowing under intact skin so 
that bridges and islands of skin remain. The char- 
acteristic features of undermining, the slow, 
extensive destruction of tissue, the pain and the 
resistance to treatment are noteworthy. Incision 
and excision of involved tissue are advised so that 
identification of the organism may be made. The 
dramatic response to flooding the entire area with 
zine peroxide tends to confirm the nature of the 
process. Skin grafting may be necessary. 

In summary, it would seem desirable to identify 
the organisms involved in these ulcerative proc- 
esses by both aerobic and anaerobic culture. 
Specific antibiotic and other therapy may then be 
more intelligently employed. Many will require 
drainage, incision, excision and skin grafting. 

E. C. B. Butler (closing): I believe there is very 
little for me to say after the two speakers who 
followed me but 1 do agree especially with Dr. Ault 
that the bacteriology of these conditions is most 
important. We do not know the cause of the 
primary ulcer but, at any rate, we can tackle the 
treatment. 






American Journal of Surgery 



SURGICAL PRINCIPLES IN THE TREATMENT OF 
PILONIDAL CYST AND ITS COMPLICATIONS 


James C. Harberson, m.d. and E. S. Brintnall, m.d. 


Watertown, New York 


Iowa City, Iowa 


I IBURT*-^ in an extensive review and 
critical analysis of the methods of treat- 
ment of pilonidal cyst and sinuses over 
the past fifteen years states, “The field, there- 
fore, is thus narrowed down to the open versus 
the closed (including partial closure) method.” 


Briefly stated these facts are as follows: First, 
over 70 per cent of the sinus tracts were simple 
midline structures which could have been in- 
cluded in a piece of tissue 2 by 2 by 5 cm. 
Second, coloring matter when injected into a 
sinus stained normal lymphatic trunks as well 


Table i 


Clinical Pathology 

No. of 
Cases 

Type of Operation 

Average 
No. of 
Days Re- 
quired for 
Complete 
Healing 

Remarks 

Pilonidal cyst, non-supporative 

2 

4 flap 

I I 


Pilonidal cyst, suppurative 

6 

4 flap 

14 



3 

4 flap with graft 

21 



I 

Modified DePrizio 

31 


Pilonidal cyst, suppurative with soft tissue abscess 

3 

4 flap 

24 


Pilonidal cyst, suppurative with fistula 

10 

4 flap 

17 


Pilonidal cyst, suppurative with fistula 

6 

Buie 

25 


Pilonidal cyst, suppurative with fistula 

2 

4 flap with graft 

21 

Coccyx excised i case 

Persistent pilonidal cyst and/or infected dead space 

5 

4 flap 

19 


Persistent pilonidal cyst and/or infected dead space 

3 

Modified DePrizio 

26 

Coccyx excised i case 

Persistent pilonidal cyst and/or infected dead space 

1 

Buie 

1 1 


Persistent pilonidal cyst and/or infected dead space 

2 

4 flap with graft 

19 



Average number of days required for healing is often used as an index of success of a given method. This is 
important from the economic viewpoint but surgically is not so significant as progressive healing and firm healing. 


He also states, “The only hope for freedom 
from recurrence and of obtaining a good me- 
chanical result, in case after case, lies in the 
open method.” He presents an excellent open 
method but concludes with the hope that the 
thoughts thus provoked might initiate a re- 
orientation in the treatment of this pathologic 
entity. / 

It is our purpose to present certain surgical 
principles applicable to this disease which if 
followed afford a rational surgical approach 
and a progressively healing wound. (Table i.) 

In 1935 Rogers and HalF undertook a 
morphologic study of the disease in specimens 
excised at operation. This study established 
certain facts which are fundamental to the 
intelligent surgical excision of a pilonidal cyst. 


as abnormal tissue. Third, there was no evi- 
dence that the constituting original defects 
had any tendency to e.xtend except as they 
were forcibly displaced by abscess and scar 
tissue^ formation. Fourth, the cause of recur- 
renc'esA\''fiS’ shown to be an infected dead space 
and not necessarily an incomplete removal of 
epithelial- tissue. ' 

The practical surgical significance of these 
facts and- the first fundamental concept in the 
treatment of this disease is that a large radical 
excision of normal and abnormal tissues is not 
necessary' for. cure. It follows that failure to 
■ oBfafri' a- C'ure'should not necessarily be inter- 
preted as failure to remove all of the cyst but 
rather a failure to obtain firm wound-healing. 

The second basic principle which we should 


January'', ig^o 


lOI 












102 


Harberson, Brintnall — Pilonidal Cyst 


like to present and emphasize can best be 
understood by a consideration of the anatomic 
factors inherent in the location of the pilonidal 
cj'^st, the function. of that area and their effect 
upon primary healing of the surgical wound. 

Between the origins of the glutei muscles on 
either side there is a relatively flat plateau 



Fig, I. Shows the flat plateau between the origin of the 
glutei muscles. 


where the aponeurosis of the sacrospinalis and 
the extension of the lumbosacral fascia overlie 
the posterior aspect of the sacrum and coccyx. 
(Fig. I.) This area is roughly triangular with 
its apex pointing toward the anus and its base 
rapidly spreading out superiorly. The buttocks 
and this intervening plateau form the cleft 
between the buttocks. 

The blood supply of the skin and subcutane- 
ous tissue on the dorsum of the sacrum and 
coccyx comes upward on either side from coccy- 
geal branches of the inferior gluteal artery 
and the superior and inferior branches of the 
lateral sacral arteries. 

The skin with adequate subcutaneous pad- 
ding droops down off the mounds of the but- 
tocks and crosses flatly across the plateau and 
then upw'ard across the buttock on the other 
side. In thin people this plateau of skin follow- 
ing the contour of the underlying supporting 
structures is readily seen. In heavier individuals 
with heavy buttocks the skin appears heaped 
up rather than flat but the contour of the 
underlying structures is the same. 

The tension lines of the skin covering this 
bony plateau between the buttocks run as if a 
flap of skin had been laid down from above 
whieh meets a flap ot skin brought up from 
below so that between the two the plateau is 


covered. The skin over the buttocks joins the 
skin over the plateau at the insertion of the 
glutei muscles and is continuous with it. 

The function, of this area is weight-bearing. 
The points of greatest pressure when a person 
is sitting upright are the two ischial tuber- 
osities. When a person sits in this fashion, the 



Fig. 2. TIic position wliicli places most stress and 
strain on the lower one-third of the pilonidal area. 

skin just posterior to the anus and that across 
the coccyx is placed under considerable tension. 
This tension pulls the skin into a straight line 
between the two ischial tuberosities and 
tends to pull it away from the subcutaneous 
structures. 

When a person sits with his thigh more 
acutely flexed on the trunk (Fig. 2), as is the 
common position when riding in the low-seated 
jeep or when sitting with the arms around the 
knees, then the coccyx, especiallj’^ at the sacro- 
coccygeal junction, becomes a direct point of 
weight-bearing along with the tuberosities; 
thus the sore “tail bone” in the common slang 
of the soldier. This particular position of flexion 
of the knees beyond a right angle in sitting 
places all the skin of the lower one-third of the 
sacral and all the coccygeal region under great 
lateral tension and direct bruising pressure. 

From these simple observations of the anat- 
omy and function of this area the second 
fundamental principle in the surgical manage- 
ment of pilonidal cyst is: To obtain firm and 
rapid wound-healing and to restore the function 
of this area the rules of plastic surgery must be 
observed which permit the return of the func- 
tions of stretching and weight-bearing over a 
bony prominence. 

American Journal of Surgery 



Harberson, Brintnall — Pilonidal Cyst 


103 


To obtain this return of function the normal 
anatomic condition should be restored. In this 
particular location the following criteria should 
be applied: (i) Incisions made in the skin for 
the purpose of draining an abscess or for the 
exposure of the cyst preliminary to excision 
must be so planned that there is a minimal of 
scarring of the skin overlying the sacrum and 
coccyx; (2) the normal relation of the skin over 
the flat plateau to that of the buttocks must be 
preserved by reestablishment of the normal 
depth of the cleft between the buttocks; (3) the 
leading point of weight-bearing must be covered 
with a full thickness of unscarred skin and 
subcutaneous tissue and (4) incisions made for 
the drainage of pus must be placed so that they . 
will not cross the lines of blood supply and 
compromise the nutrition of future skin flaps. 

To obtain rapid and firm wound-healing in 
an area where the wound overlies a bony 
prominence and is subject to unavoidable ten- 
sion and contamination the following criteria 
should be applied: (i) Complete healing must 
not depend upon the obliteration of dead space 
under tension; (2) healing must not depend 
upon the process of granulating in to such a 
depth that vascularity is impaired and early 
prompt epithelization cannot take place; (3) 
healing must not be unduly disturbed by the 
unavoidable tension on the site and (4) infec- 
tion if it occurs must neither unduly delay 
healing nor prevent firm wound-healing. 

When this group of criteria is applied to the 
various operative procedures encountered in 
the treatment of pilonidal cyst, the causes for 
delayed healing or failure to heal become 
apparent. 

The open operation in which the elliptical 
skin incision is used is comparable as a pro- 
cedure to the amputation of a finger or leg 
without preserving normal skin as flaps to 
cover the bone. This normal skin is urgentlj^ 
needed. When this excision of skin is combined 
with a block excision of normal and abnormal 
tissue, we have an unfortunate situation 
created by the surgeon and not by the demands 
of the disease for cure. The skin which should 
have been used to cover the area is thrown 
away and the blood supply to the center of the 
healing area has been interrupted by excision 
of normal vascular subcutaneous tissue. The 
depth of the granulation tissue which must fill 
this cavitj' with its bonj'^ base is so great that 
its vascularity is impaired and it will not readil}' 

Jamian', 1950 


support epithelization. When the feeble effort 
at epithelization over this poorly nourished 
base IS constantly interrupted by unavoidable 
tension, the end result is an indolent fissure or 
a poorly nourished scar which will not stand 
up under the trauma of use. 

The basic defect in the closed procedure is 
that an attempt is made to obliterate dead 
space in a location where tension is unavoid- 
able. In accomplishing this a portion of the 
normal cleft between the buttocks is obliter- 
ated and bridged over by suture. This raises 
the line of pull from the attachment of the 
glutei along the sacrum and coccyx to a higher 
level and thus shortens the line of pull between 
the tuberosities and increases tension on the 
suture lines. This static tension when added 
to the tension from flexion of the thighs makes 
security in obliterating dead space difficult to 
obtain. The cleft is placed there to help absorb 
this lateral pull and should be restored. Again 
these wounds break open, as would be e,xpected, 
at the place of greatest lateral pull, the lower 
one-third of the wound. 

McCutchens® has emphasized some of the 
aforementioned principles and has described 
an operative method similar to the one we 
have used. However, the incisions he uses 
allow tenting of the upper and lower skin flaps 
with resulting dead space and infection. 

TECHNIC 

It is not the author’s intention to present one 
operative procedure and to imply that good 
results cannot be obtained by other procedures 
which have appeared in the literature. Our 
interests have been concentrated upon the 
failures and upon an attempt to understand 
why the difficulties arose. During this study 
we have developed an operative technic which 
meets all the criteria listed before. During the 
past five years with the exceptions discussed 
later it has been our method of choice for the 
primary excision of pilonidal C3’^sts. Since 
excision of the cyst follows the successful 
management of the acute complications, we 
will present the management of the acute stage 
and then describe a technic for excision. 

Pilonidal Abscess. When infection occurs in 
a pilonidal cyst, the suppuration maj" be con- 
fined to the cj'^st or it maj^ break through and 
form an adjacent soft tissue cellulitis. In either 
instance the object of treatment is to arrest 
the inflammation and not to cure the disease. 



104 


liarberson, Brintnall — Pilonidal Cyst 


It is in this stage of the disease that a great 
deal of grief and trouble to any future effort 
may be caused by thoughtless surgery. The 
practice of laying it wide open in the hope that 
a cure will be obtained is wrong. (Fig. 3A.) A 
large midline scar results which compromises 
the intelligent planning of the surgeon when he 
operates for cure. 


scarring of the skin covering the midline 
plateau and do not compromise its blood 
supply. _ 

Excision. The object of surgical excision is 
to cure the surgical lesion. The procedure used 
by us is as follows; 

The area is first inspected to locate all the 
primary sinus openings. The location of the 



Fig. 3. A, poorly placed incisions for drainage of pus in the pilonidal region; n, properly placed 
incisions for drainage of pus in the pilonidal region. 


Fig. 4. Shows outline of skin incision for the four-flap method of excision of 
pilonidal cyst. The artist has placed the lower arms of the incision top far out 
over the buttocks; they should follow the attachments of the gluteal muscles. 



The treatment should be conservative and 
should consist of bed rest and hot fomentations. 
If incision becomes necessary, a small radial 
nick in the highest and most lateral portion of 
the distended cyst, should be made. (Fig. 3B.) 
In like manner, a radial incision made for 
drainage of a soft tissue abscess should be 
placed as high and as far laterally on the abscess 
as possible. (Fig. 3B.) These incisions avoid 


cyst and any secondary sinus tracts is deter- 
mined by palpation. With methylene blue four 
flaps are outlined on the skin. The upper and 
lower flaps are the important ones and should 
be outlined to follow the normal contour of the 
attachments of the glutei muscles. (Fig. 4O 
Where the upper and lower flaps meet, a small 
section of skin which contains the sinus opening 
is marked off for excision. The two lateral flaps 

American Journal oj Surgery 



Harberson, Brintnall^ — Pilonidal Cyst 


105 


are automatically outlined by planning the soft tissue beneath this, flap. (Fig. 5B.) These 
upper and lower flaps. These incisions bring sutures reapproximate closely the soft tissue 
the lines of healing over a soft tissue and not a incised in elevation of the flap and fix the flap 
bony base. at the desired level. This flap should be flat 

Each flap is carefully elevated to avoid cut- and snug, 
ting into underlying diseased tissue. (Fig. 5A.) The upper skin flap is dropped back into a 
Hemostasis is obtained with .plain No. 0 catgut position where it will lie flatly over the upper 



Fig. 5. A, exposure and removal of cyst after elevation of four skin flaps; n, suture of 
the lower skin flap. 


and hot moist packs. The cyst and its sinuses lie portion of the wound and fixed to the fascia 
clearly in view and are cleanly excised by sharp over the sacrum with silk sutures. The two 
dissection. Excision is easily done and does not lateral flaps are dropped back into place and 
require denuding the sacral fascia. The wound sutured with silk to the lumbosacral fascia 
and the under surfaces of all the flaps are at the line where the glutei muscles are at- 
palpated and inspected for any residual diseased tached. The four arms of the incision are 
tissue. The excised specimen is cut open and approximated with interrupted silk sutures, 
inspected for any missing portion. The instru- (Fig. 6b.) A pressure dressing which places 
ments used to inspect the specimen are dis- upward pressure on the lower flap and down- 
carded and the surgeon changes gloves. When ward pressure on the upper flap is applied with 
it appears that all diseased tissue has been rolled gauze sponges and adhesive strips, 
removed and that good hemostasis has been Buie Melhod of Marsupializalion. In cysts 
obtained, the wound is closed. which lie superficially we have used the Buie® 

In closure particular attention should be technic of marsupialization. A superficial cyst 
given to the position of the lower skin flap. It can be e.\pected if there'are multiple tiny mid- 
is desirable that this flap cover the sacro- line sinuses or if there are two or more palpable 
coccygeal joint by suturing it into a position subcutaneous sinus tracts e.\'tending over the 
slightly higher than normal. (Fig. 6a.) This is adjacent tissue areas. 

best accomplished by a series of sutures in the The Buie technic of marsupialization was 
January, ig^o 



io6 Harberson, Brintnall — Pilonidal Cyst 

chosen for this group of cases for several of the wound is impaired, can only lead to 
reasons. The multiple tiny midline sinuses may further trouble. The problem is comparable to 
extend over a distance of 4 or 5 cm. To eradicate that encountered in severe injuries of the lower 
them would require an excision of a long strip leg in which indolent scarred areas over the 
of midline skin. These tiny openings may tibia must be replaced by a full thickness skin 
extend down into-the moist skin near the anal graft before an acceptable result is obtained. 



Fig. 6. a, position of lower skin flap; u, completed operation; c, sliows small area 
of excised skin. 


sphincter. Excision of the skin containing the Unfortunately the surgeon often finds that 
' sinuses to this point does not leave sufficient he does not have the material, primarily normal 
area to develop a skin flap to seal off the lower skin, to accomplish what he wants to do. There 
end of the wound and to cover the weight- is insufficient skin to cover the midline plateau 
bearing point of the spine with a full thickness and sometimes, in addition, there is insufficient 
of skin free of scar. The most important reason skin laterally to reach down to the level of the 
for using this method is that the wound heals lumbosacral fascia. The degree of difficulty 
and is not pulled apart by the movements of which he will encounter depends directly upon 
the patient. the type of previous surgical treatment. The 

Secondary Operation Jor Residual Pilonidal skin which the surgeon would like to use to 
Cyst and Jor Chronically Injected Dead Space, cover the plateau between the buttocks is lost 
The .problem confronting the surgeon in these either from surgical excision or from excessive 
cases is similar. The scar tissue and cyst scarring. In addition, in those cases in which 
remnants must be excised and the wound the normal depth of the cleft between the 
revised so that it can heal without the necessity buttocks has been decreased, the surgeon will 
of excessive granulation tissue formation or find that the skin coming down off the buttocks 
the necessity of obliterating dead space under has adjusted itself by shortening and cannot 
tension. The procedure must be radical. Con- readily be sutured down to the lumbosacral 
servative efforts, especially when the nutrition fascia. The third difficulty which previous 

American Journal of Surger^r 


•I 


Harberson, Brintnall — Pilonidal Cyst 


107 



Fig. 7. A, photo on fourteenth day following excision of 
pilonidal cyst. 


surgery causes is that incisions made for drain- 
age of an abscess may compromise the blood 
supply of the skin flaps. All of these factors 
enter into a longer hospital stay, a longer 
healing period and a less satisfactory end result. 

It is impossible to present one skin incision 
suitable for all of these cases. The operation is 
more properly scheduled as e.xcision of scar 
tissue and revision of wound. We have tried 
whenever possible to create the four skin flaps 
as described previously and to reestablish the 
normal relations of the area. This is essentially 
the reestablishment of the normal depth of the 
natal cleft and the, sealing off of the lower end 
of the incision with a skin flap which covers the 
sacrococcygeal joint. The latter step we think 
most important to obtain. 

When conditions make it impossible to create 
all of these flaps, a modification of the operative 
method described by DePrizio'' is often helpful. 
In this procedure the scar in the skin and all 
underlying scar is completely e.\clsed. If there 
is sufficient normal skin left at the lower end to 
form a skin flap, however short the flap, this is 
done and sutured down securely. The skin 
coming down off the buttocks is sutured to the 
lumbosacral fascia near the buttocks. When it 
is possible to create a skin flap at the upper 
end, this is also done. No effort is made to cover 
the plateau between the buttocks unless there 
is sufficient skin from the upper and lower 
flaps to do so. Pinch grafts are placed over all 
uncovered areas. 

Excision oj the Coccx'x. We do not believe 
excision of the coccjo: is often necessarj’- to 

January, ig^n 





Fig. 7. B, photo showing complete healing on the four- 
teenth day following excision of pilonidal cy.st. 


eradicate the cystic elements of a pilonidal 
cyst completely. However, there is an occa- 
sional individual who has a deformed coccyx 
with its tip projecting posteriori}' in such a 
manner as to make it difficult to suture the 
lower skin flap flatly into place. In this indi- 
vidual the deformed cocc}'x should be excised. 

POSTOPERATIVE CARE 

The patient is kept at absolute bed rest for 
five to seven days. The sutures are removed 
from the fifth to seventh day. Pressure dress- 
ings are maintained throughout the patient’s 
stay in bed. 

The prolonged bed rest is mandatory. We 
have not been able to rationalize ambulatory 
treatment in a condition in which primary 
progressive wound-healing is so important. 

At the end of ten days the wound should be 
healed with the exception of the small area 
where the upper and lower flaps did not quite 
approximate. (Fig. 6c.) This area will vary in 
size from 0.5 cm. square to i cm. square. If the 
skin flaps are sealed down firmly, it is not 
necessar}' to keep the patient in bed to await 
epithelization of this area. 

The after-care of the healed wound is of 
utmost importance. It must be impressed upon 



io8 


Harberson, Brintnall — Pilonidal Cysl 


the patient that out of sight is not to be out of 
mind. It is his responsibilitj' to care for and 
protect the healed wound. (Fig. 7A and B.) 

The patient is instructed to cleanse the area 
daily by gentle washing and drying. If the 
individual is obese or perspires easily, he is 
instructed to apply borated talc after each 
cleansing. The last instruction given is to avoid 
sitting on the tip of the spine. 

It does not seem reasonable that any wound 
which carries the potentialities for trouble 
that wounds in this area carry should be dis- 
missed from the mind of the surgeon and be 
e.xpected to withstand thoughtless and uncon- 
trolled trauma. For this reason we protect the 
area for a sufficient period of time to allow a 
safe return to its full function ofweight-bearing 
under stress and strain. 

SUMMARY 

A discussion of the causes for insecure wound- 
healing in the surgical treatment of pilonidal 
cysts is presented. 

The persistence in the use of the terms open 
and closed has retarded an appreciation of the 
basic surgical problem which this disease 
presents. 

The function of weight-bearing must be 
restored by covering the sacrococcygeal junc- 
tion with normal full thickness of skin and 
subcutaneous tissue. 

The normal depth of the natal cleft must be 
restored to avoid any attempt to obliterate 
dead space. 

The flat plateau over the sacrum between the 
attachments of the glutei muscles must be 
protected from scarring and returned to its flat 
position. Block excision of normal and abnor- 
mal tissue is not necessary for cure. 

Methods to accomplish these results arc 
presented. Forty-four cases are tabulated in 
which patients were .treated after these 
principles. 

REFERENCES 

1. Liburt, Joseph. Pilonidal cyst and sinus. New 

England J. Med., 238: 806-808, 1948. 

2. Idem. Nexv England J. Med., 238: 840-843, 1948. 

3. Rogers, H. and Hall, M. G. Pilonidal sinus: sur- 

gical treatment and pathological structure. Arcb 
Surg., 31; 742-766, 1935. 

4. DePrizio, Carl J. Pilonidal cysts and a new im- 

proved type of operation. Mil. Surgeon,- : 292, 
1942. 

5- Buie,' L. Jeep disease (pilonidal disease of mecha- 
nized warfare). South. M. J. 37: 103— 109, 1944. 


6. McCutchens, G. T. Pilonidal sinus: application of 
plastic surgical principles in new surgical ap- 
proach. Ann. Surg., 118:430-437, 1943. 

DISCUSSION 

Karl Zimmerman (Pittsburgh, Pa.): Doctors 
Harberson and Brintnall have put a great deal of 
time and thought into their paper. The funda- 
mental anatomic and surgical facts on which they 
base their treatment arc sound. They should be 
congratulated on their thoroughness. The success 
of the authors’ closed method is confirmed. 

The authors say that skin must be preserved; 
the best way to preserve skin is not to remove it. 
In the section of this paper on marsupialization a 
statement is found to the effect that the base of the 
cyst furnishes an ideal framework for epithclization 
which cannot be pulled apart by movements of the 
patient. This is true so why remove the base? 
Doctor Harberson quotes Rogers and Hall. 
“Failure to obtain a ‘cure’ is not necessarily to be 
interpreted as failure to remove all the cyst but 
rather a failure to obtain sound wound healing.” 
If this is true, why does not an infected pilonidal 
cyst heal like most other abscesses when adequate 
incision and drainage is established? The main 
reason is because it has foreign material in it. This 
foreign material is usually hair and desquamated 
epithelium. 

An infection of the face that has an ingrowing 
hair in it will not heal unless the hair is removed. 
An infected surgical wound containing a non- 
absorbable suture will not heal unless the suture is 
removed. If a child gets a splinter in his foot and 
the wound becomes infected, it will not heal as long 
as the splinter is in it. These wounds will heal if the 
foreign material is removed. The same principle 
applies to pilonidal disease. 

The answer is simple. A probe is passed into the 
tract or tracts and the overlying tissue separated; 
the tracts arc wiped clean with gauze and wet 
dressings applied. The wound must be watched. 
Failure of any part of the wound to produce 
healthy granulations means that some foreign 
material has been left. Such an area if found is 
again wiped clean. 

One hundred si.xty-three cases in which patients 
were treated with this method were reported at the 
American Proctologic meeting in 1946. One 
hundred fifty-three more cases can now be added 
with two known recurrences. The average number 
.of days from operation to complete epithelization 
has been twenty-three. Hospitalization need not 
be more than four days. Less extensive cases are 
done in the office. 

What was the recurrence rate in Dr. Harberson’s 
cases? 

Robert J. Morrow (Lansing, Mich.): The 
paper by Doctors Harberson and Brintnall brings 

American Journal of Surgery 



Harberson, Brintnall — Pilonidal Cyst 


109 


out some good points in technic for the cure of this 
condition. 

The ideal surgical procedure is excision with 
primary closure. However, we know the great 
tendency for the sutured cyst walls to pull away 
from fascia over the sacrococcygeal area, thus 
leaving a dead space which fdls with serum and 
later purulent material defeating primary healing. 
One can get primary healing if the sinus tract 
extends laterally and caudal from Oehlechers bald 
spot by excision and primary closure. However, 
there may be some breaking down of the portion 
of the sinus tract in the midline. 

It is very important to make a thorough study 
of the type of procedure necessary to follow at one’s 
first operation as the recurrent operations are the 
more difficult due to the loss of skin and replace- 
ment of scar tissue. The DePrizio operation and 
pinch grafts on areas refusing to epithelize are 
best suited to this type of cyst as the authors have 
stated in their paper. The primary incision to free 
pus to either side of the midline is an important 
procedure in the future repair of the cyst. 

The flap technic might be called the H operation 
due to its resemblance to the letter H when 
completed. Healing has been rapid and satisfactory 
with this procedure. I am wondering if raising 
large flaps might cause some slough at times. My 
experience at North Sector General Hospital was 
limited to only a few cases in which the wounds 
healed readily in fourteen to twenty-one days when 
an order came through to discontinue raising flaps 
for pilonidal cysts. 

It is interesting to note that we saw no pilonidal 
cysts in the yellow or red races. In a personal com- 
munication from Dr. Judd of Honolulu he stated 
that he had never seen a pilonidal cyst in a pure 
Hawaiian. This supports the ectodermal invagina- 
tion theory; these races have verj" little hair on 
their bodies to cause chronic irritation from growing 
under pressure when they attain the adolescent 
age. 

In our series at North Sector General Hospital of 
ninety patients with pilonidal sinuses who went to 
surgery from January i to November i, 1944, the 
average hospitalization from time of surgery to 


discharge was 34.6 days; the average age was 
twenty-four years one month, these patients being 
ready for full duty when discharged from the 
hospital. The operative technics were as follows: 
seventy-seven .exteriorizations, seven H-shaped 
incisions and complete excision, five incisions and 
drainage and one primary closure. Nine of these 
patients had recurrent pilonidal sinuses for which 
they were previously operated upon, seven by 
excision and primary closure, one exteriorization 
and one multiple incision and drainage. With the 
exteriorization method one must use a fine probe 
such as a lacrimal duct probe. Also, one must be 
sure no sinus tracts are left and must excise a 
small, V-shaped piece of the floor of the cyst close 
to the skin margin which allows the fine silk sutures 
to make better apposition of the skin to the floor 
of the cyst. When healing was slow, I used a solu- 
tion of thiamin hydrochloride as topical application 
covered with vaseline gauze to keep the solution 
in contact with slow granulating tissue. Healing 
was very rapid after this treatment in some of the 
areas that refused to heal. 

Ja.mes C. Harberson (closing): Time did not 
permit discussion of the various operative pro- 
cedures which we tried and with which we found 
trouble. I used the extreme of the open method 
and the extreme of the closed as an example. 

We have tried the much more intelligent open 
method in which only abnormal tissue is excised 
but we encountered the same type of difficulty in 
some types of these cases. We must remember that 
it is the ones who get into trouble after this type of 
operation that are our headaches. 

In regard to recurrences I would like to answer 
that in this way: I have accepted the work of 
Rogers which has indicated that excision of abnor- 
mal tissue is all you need to do to cure the cystic 
element of the disease. I think it was careful work. 
In 400 cases Rogers found 3 per cent recurrences. 

Most of our patients were seen in the Army 
where you just do not have an opportunity for a 
satisfactory follow-up. I have not had any trouble 
with the mechanical aspects of any of these wounds 
treated in civilian life and none of them have shown 
any recurrence or needed a secondary operation. 




January, ig^o 



COCCYGODYNIA 


THE MECHANISM OF ITS PRODUCTION AND ITS RELATIONSHIP 

TO ANORECTAL DISEASE 

George H . Thiele, m.d. 

Kansas City, Missouri 


D ORLAND defines coccygodynia as pain 
in the coccyx and neighboring regions 
due to rheumatism, neuralgia or injury 
to the bone. 

While it is true that in patients with direct 
injury the pain is most often localized in the 
coccyx itself, it is also true that in about 85 per 
cent of the patients the pain is not in the coccj'x 
but is either in the sacrococcygeal joint or in the 
muscles which are partially inserted into the 
lateral borders of the coccyx. These muscles 
are the levator ani, the coccygeus and a 
bundle of fibers from the gluteus maximus. It is 
my opinion that coccj'godynia is far less fre- 
quently rheumatic or neuralgic than is com- 
monly believed. 

In 1936 I presented before this Society a 
preliminary report on the treatment of coc- 
cygodynia by massage of the levator ani and 
coccygeus muscles. The material upon which 
that report was based consisted of only twelve 
patients. The conclusions presented in this 
paper are based upon 169 patients with coc- 
cygodynia who have been treated in private 
practice since March, 1934. There were twenty- 
seven males and 142 females. The average age 
was forty-tNvo years. 

The basic concepts of the causes and treat- 
ment of this syndrome as outlined in four 
previously published papers have not changed 
and I shall quote freely from those papers in 
this regard. 1“'* 

Perusal of the literature reveals that coc- 
cygodynia has been thought to result from one 
or more of the following; neurosis, neuritis, 
neuralgia, rheumatism, sprain, luxation* and 
fracture. Treatment has included such internal 
medication as sedatives, antineuritics and anti- 
spasmodics, and the use of counterirritants, 
rectal suppositories, hot applications,® cold 
applications, electrotherapy, massage of the 
coccyx,^ injection of local anesthetics,®-*" x-ray 
therapy** and coccygectomy.*" 

The first contribution offering a logical expla- 

1 10 


nation for the symptoms and findings in coccy- 
godynia was made by Sir James Y. Simpson.'"' 
He stated that when the coccyx or coccygeal 
joints have been injured or when the surround- 
ing structures were the seat of inflammation, 
any contraction of the muscles connected with 
the coccyx would excite the characteristic pain 
of coccygodynia. He further noted and stressed 
the fact that unilateral contraction . of the 
coccygeus or levator muscles would pull the 
coccyx laterally and antcriorljq and when these 
muscles contracted bilaterally, the coccyx 
would be pulled forward. He added that due 
to the origin of a portion of the gluteus maximus 
from the side of the cocejo: any contraction of 
these muscles such as in walking, sitting down 
or arising from a sitting position would move 
the sacrococcygeal joint. He attributed pain 
during defecation to the contraction of the 
Icvatorcs ani. He attributed the greater inci- 
dence of coccygodynia in the female to the 
greater size of the female pelvis and the conse- 
quent greater development of the pelvic 
muscles. He stated that coccj'godynia was not. 
necessarib’- caused b}' parturition. 

Fifteen years’ observation has impressed me 
with the fact that Simpson’s basic conceptions 
of coccygodynia were entirely correct. He did 
not, however, mention muscle spasm as the 
direct cause of this s^mdrome nor did he recog- 
nize the etiologic factors other than trauma 
which account for the vast majority of cases of 
coccygodjmia. 

Etiologi''. Any focus of infection, the Em- 
phatic drainage from which is toward the pelvic 
muscles, may cause myositis or reflex spasm of 
those muscles resulting in coccygod3mia. (Fig. 
i.) Infection was the etiologic factor in 108 of 
the 169 cases. The infection was found in the 
anus in 103, in the cervix in two, in the prostate 
in two and in the epidj'dimis in one. (Table i.) 

In fortj^-nine of the 169 cases here presented 
trauma seems to have been the etiologic factor. 
In five of the twenty-five patients who fell 

American Journal of Surgery 


Thiele — Coccygodynia 


1 1 1 


there was roentgenographic evidence of frac- 
ture. Five of the falls occurred in pregnant 
women during the last few days or weeks of 
pregnancy. Parturition was the traumatic 
factor in three. Bumps against furniture ac- 
counted for six, surgical procedures for two and 


Table i 

ETIOLOGY IN 1 69 CASES* 


Infection io8 

Anal 103 

Cervical 2 

Prostatic 2 

Epidydimal i 


Trauma 49 

Falls 25 

Fracture 5 

Pregnancy j 

Prolonged rides 12 

Bumps on furniture 6 

Parturition 3 

Miscellaneous 3 

Postsurgical 10 

Miscellaneous , 2 

Spinal cord tumor i 

Herniated disc i 


* It will be noted that anal infection heads the list as 
an etiologic factor. Five of the patients who suffered 
falls were women in the later days of pregnancy. 



Fig. I. Schematic drawing showing the lymphatic 
drainage from the anorectum; myositis with tender- 
ness and spasm of the affected muscles may result 
from anorectal infection. 


bullet wounds in military service for one. 
Prolonged automobile rides were considered as 
a traumatic factor in twelve patients. (Table i.) 

Mild symptoms such as aching in the region 
of the coccjTc and of rectal heaviness sometimes 
appear following recovery from anorectal 
surgery. 

A spinal cord tumor was present in one and 
herniation of the intert'^ertebral disc in one. 

As will be explained later continued poor 
posture may be a contributory factor in the 
etiology of coccygodynia. 

History. The chief complaints of patients 
with coccygodynia are tenderness and pain or 
aching localized in the lower portion of the 
sacrum and the coccyx or in the adjacent 
muscles and soft tissues. The patient usually 
says he has pain in the “tail-bone.” 

In this series of 169 cases when the patient 
was first seen, symptoms had existed for an 
average period of about two years, the time 
varying from one day to thirty-five years. It is 
worth noting that the patient who had had 
coecygodynia for thirty-five years was cured 
as the result of anorectal surgery and massage 
of the spastic muscles. 

When direct trauma has recentlj^ occurred, 
pain and tenderness may be the outstanding 

Januaryr, ig^o 


symptoms. If sudden trauma has been the 
causative factor, muscle spasm occurs at once 
and the onset of pain and tenderness is sudden. 
If, on the contrary, trauma has been gradual 
as in continued automobile riding, the onset 
of symptoms is more gradual. An insidious 
onset of pain is also the rule in those patients in 
whom muscle spasm is secondary to focal 
infection. It is in these non-traumatic cases 
that the physician will later be surprised to 
find during his e.xamination that pressure on 
the coccjoc does not elicit tenderness. 

Except in cases of severe trauma or fracture 
pain is not increased during defecation. 

Almost without exception one may elicit 
the history that a long automobile ride or 
prolonged sitting will produce such sev'ere pain 
that these should be avoided whenever possible. 
The severity of the pain is in direct proportion 
to the length of time that sitting is continued 
without interruption but is most severe during 
the act of arising from that position. 

In the majority of the non-traumatic cases 
careful questioning will reveal that the patient 
has had symptoms of anorectal disease. 

Almost entirely without exception women 
within the menstrual age will state that all 
coccygodynic sjTuptoms are greatly exacer- 



I 12 


Thiele — Coccygodynia 



2A 2n 

Fig. 2. L-ntcral vicw.s of the .sacrum and coccyx witli patient sitting on a hard table. A, patient 
sitting up straight in good posture; d, patient sitting in slumped position. Note that pressure of 
the coccyx again.st the table produces acute angulation of the coccygeal joints. 


bated just preceding and during the menstrual 
period. 

Male patients should be questioned about 
the symptoms of posterior urethritis, prostatitis 
and seminal vesiculitis. In the female it is well 
to ascertain whether there has been bladder 
Irritability or a purulent vaginal discharge. 

As has been stated and as you have all ob- 
served, mild symptoms of sacrococcygeal 
aching or a sense of heaviness and weight in 
the lower rectum not infrequently follow a few 
weeks after anorectal surgery. 

About one-third of the patients will give a 
history of associated pain in the upper portion 
of the gluteal region and/or down the posterior 
portion of the thigh along the course of the 
sciatic nerve. 

Examination, Physical Findings and the 
A'lechanism of the Production of Symptoms. 
The patient with coccygodynia will sit down 
slowly and carefully, usually shifting his 
weight to one buttock. The sitting position is 


changed frequenti}’-; and when the patient 
arises after continued sitting, it is often with 
obvious pain and effort. This is due to tension 
on the cocej’x by fibers of the gluteus maximus 
which must contract in order to e.\tend the 
thigh and raise the body. 

It has been obser\'ed that most patients with 
coccygodynia habitually sit in poor posture 
with the lumbosacral portion of the back con- 
vex instead of concave, thereby slumping in 
the chair and .allowing the middle portion of the 
buttocks, the sacrum and the coccyx, which is 
cushioned only by scanty overlying soft tissues, 
to press against the chair. This pressure pro- 
duces pain more through continued overflexion 
of the sacrococcygeal joint than through pres- 
sure per se on the coccyx itself. This is evi- 
denced by the fact that the average patient is 
more uncomfortable when sitting in an up- 
holstered chair in poor posture than when 
sitting on a hard chair in good posture. It 

American Journal of Surgery 


113 


Thiele — Coccygodynia 



Fig. 3. This sketch shows the position of the index finger palpating the levator ani and coccygeus muscles. By 
rotating the hand and examining finger all portions of the levator ani may be carefully palpated. 

Fig. 4. Unilateral contraction or spasm of the levator ani (or coccygeus) pulls the coccyx laterally and 
anteriorly produeing stress on the sacrococcygeal and coccygeal joints. 


would seem that continued poor posture may 
produce reflex muscle spasm. (Fig. 2.) 

Before proceeding with the examination of 
the patient it -is well to remember that the 
sacrococcygeal joint is freely movable to this 
extent; anteroposterior flexion and extension 
of the coccyx with relation to the sacrum is 
normal through an arc of about 30 degrees. The 
tip of the coccyx may normally be moved 
laterally about i cm. from the midline. Mobility 
of the coccyx is therefore not a sign of disloca- 
tion or fracture. 

Moderate pressure against the tip of the 
coccjix does not cause pain in the normal indi- 
vidual. Moreover, it does not increase the 
pre-existing pain even in those individuals with 
coccygodynia of non-traumatic origin. It does, 
however, generally exacerbate the pain in those 
patients whose coccygodynia is of definite 
traumatic origin. 

With the patient in the left lateral Sims’ 
position the examiner should proceed as 
follows: Insert the gloved finger full length 
into the rectum, place the thumb over the 
cocejo: externally and palpate the coccyx be- 
tween the thumb and finger. 

Janiian,!’, ig$o 


The coccyx may be moved through its 
normal range of mobility; but more often than 
not when coccygodynia is present, such move- 
ments will cause pain. Exquisite tenderness 
should lead one to suspect fracture. I f fracture 
is present, any movement of the bones will be 
extremely painful and crepitation may be felt. 

Next, move the finger laterally from the 
posterior midline, maintaining the flexor surface 
of the finger in contact with the soft tissues. 
The finger is now lying on the medial fibers of 
the gluteus maximus and on the levator ani 
and coccygeus as they proceed to their insertion 
into the lateral edges of the coccyx and lower 
portion of the sacrum. With moderate pressure 
move the finger laterally, anteriorly and then 
medially describing an arc of 180 degrees until 
the finger lies just posterior to the symphysis 
pubis. You have now palpated all of the fibers 
of all muscles which are inserted into the latera 
border of the coccjoc. (Fig. 3.) 

When coccygodynia is present, the most 
typical and characteristic findings are muscle 
tenderness and spasm. Because the coccygeus 
muscle lies directly upon the unyielding sacro- 
spinous ligament, spasm of this muscle is more 



Thiele — Coccj'godynia 


1 14 



Fig. 5. During spnsin or contraction of tlic piriformis 
muscle its lower border inaj' produce pressure on the 
sciatic nerve. Similarly, tlie upper border of the 
piriformis may press the superior gluteal nerve against 
the lotver border of the gluteus medius and produce 
pain in the superior gluteal region. Spasm of the 
piriformis muscle accounted for sciatic and superior 
gluteal pain in about one-third of the patients with 
coccygodynia. 

difficult to determine than is spasm of the 
levator ani -which is freelj' suspended from its 
points of origin and insertion supported chiefly 
by adipose tissue. Because of the underlying 
ligament the relaxed coccygeus may therefore 
be mistakenly thought to be in a state of spasm. 

When the entire levator ani is spastic, it will be 
felt as a firm sheet of muscle tensely stretched 
from its origin in the obturator fascia to its 
insertion into the lateral borders of the coccyx 
and lower portion of the sacrum. 

If the patient is instructed to strain down, 
the spastic muscles will often relax while being 
palpated. Muscle spasm and tenderness may be 
unilateral or bilateral. If unilateral the stress 
on the sacrococcygeal joint is in the direction 
of flexion and abduction; if bilateral it is in the 
direction of anterior flexion. (Fig. 4.) 

In the male the prostate and seminal vesicles 
should be palpated; in the female the cervix 
should be visualized. 

Anoscopic examination may reveal anal 


infection. It should be mentioned that inno- 
cent-appearing crypts not infrequently harbor 
the infection responsible for the muscle spasm 
found on palpation. 

In my opinion coccygodynia is due to three 
factors. First, direct trauma may, of course, 
cause pain. Second, continued immobilization 
of any joint maintained in a position of flexion 
by muscle tension will cause pain in that joint. 
In coccygodjmia the sacrococcygeal joint is 
maintained in a state of constant flexion by 
tension of the spastic levator ani and coccygeus 
muscles. Tliird, muscle spasm itself may be 
painful. W’c are taught that repeated or sus- 
tained muscle contraction results in the forma- 
tion of lactic acid which first causes fatigue and 
then pain. Anoxia may also be a factor. 

The mechanism of the production of hip and 
leg pain which so often accompanies coccygo- 
dynia has been discussed in a previous paper.-'' 
It need only be mentioned here that such pain 
is caused b^’ pressure of an associated spastic 
piriformis muscle on the sciatic ner^’e as it 
emerges through the sacrosciatic foramen, and 
upon the superior gluteal nerve as it passes 
between the upper border of the spastic 
piriformis and the lower border of the gluteus 
medius. (Fig. 5.) Spasm of the piriformis muscle 
bears no causative relationship whatever to 
coccygodynia; it is merely concomitant with 
spasm of the levator ani and cocc3'geus and is 
due to the same causes. 

Diagtxosis. The diagnosis of coccj'godjmia 
involves the following factors: pain in the 
region of the COCC30: and lower portion of the 
sacrum and in the adjacent muscles and soft 
tissues. Coccvgod3mia is derinitel3'^ and char- 
acteristicall3'^ exacerbated b3’- continued sitting 
and is characteristicall3’^ most severe during the 
act of arising from the sitting position. Tender- 
ness on pressure against the tip of the coccyx is 
present in cases of recent traumatic origin but 
in those cases in which muscle spasm has 
resulted from chronic focal infection pressure 
against the cocc3'geal tip usuall3’- does not 
increase the pain. The spastic muscles arc 
invariabl3’- tender. 

Cocc3’'god3mla must be differentiated from 
pilonidal inflammation and from anorectal 
disease although it may accompan3" either. 

Treatment. The treatment of cocc3"god3mia 
consists of massage of the spastic muscles 
attached to the sides of the coccyx and of the 
medical or surgicaFcontrol of focal infection. 

American Journal of Surgery 



Thiele — Coccygodynia 


Massage is performed as follows; With the 
patient in the left lateral Sims’ position the 
finger is inserted into the rectum, its flexor 
surface lying across the bellies of the levator 
ani and coccygeus muscles. Massage is applied 
with a stropping motion, moving back and 
forth lengthwise along the muscles from their 
origins in the lateral wall of the pelvis to their 
insertions into the lateral borders of the lower 
sacrum and coccjrx. (Fig. 6.) Massage is re- 
peated with only as much pressure as the 
patient can tolerate without too much pain. 
The movements are repeated gently from ten 
to fifteen times and the patient is instructed to 
strain down. The spastic muscles maj’’ relax 
during the massage. Massage is repeated daily 
for four to five days, then every other day for 
a week and gradually less often until pain has 
disappeared and further massage is unneces- 
sary. Definite improvement is generally evident 
within ten days. Massage at gradually less 
frequent inter\'als may be required for several 
weeks. 

When pain has not been relieved by massage 
together with medical treatment of the foci 
of infection which may exist and if spasm is 
still present, one is justified in recommending 
the surgical removal of foci of infection. 
Removal of anal ulcers, crypts, hemorrhoids 
and fistulas should be done with meticulous 
care even though the gross appearance of these 
structures maj’" not seem to demand their 
removal. Infected crevices should be cauterized. 
Meticulous surgerj' will pay big dividends. 

Granet,''* Wilkinson'® and others have con- 
firmed my observations and have reported 
similar results with treatment bj'^ massage. 

A score or more of patients have consulted 
me only after having been advised to have the 
coccjo: removed. Coccygectomy had been per- 
formed elsewhere on five patients without 
relief of coccygodynia. As a result of massage 
of the levatores four of these patients were 
markedly relieved and one was unimproved. 
It cannot be said that any of the five were 
cured. One cannot too strongly question 
coccygectomy as a cure for coccygodynia. 

Results. Of the 169 patients 124 were 
treated by massage only. Of these, sLxty-nine 
(56 per cent) were cured, forty (32 per cent) 
were relieved to the point that they were com- 
fortable under all ordinary circumstances, ten 
(8 per cent) were unrelieved and in five (4 per 
cent) the results were questionable. Operation 
for removal of focal infection was advised but 

January', igjo 


I I 



Fig. 6. Illustrates the movements of the finger used in 
massage; movement of the anal ring in the perineum 
allows pressure of the llevor surfaee of the base of the 
finger against the mesial (puboeoccygeal) portion of 
the levator and its insertion into the anal musculature. 


was refused by thirteen of the fifty patients 
who were not cured. 

Of the 169 patients forty-live were treated 
with massage and surgical removal of foci of 
infection. Of these forty-five patients thirty- 
eight (85 per cent) were cured, six (13 per cent) 
were relieved and one was unimproved. 

Table ii 

RESULTS or TREATMENT OK 169 PATIENTS 


Treated by massage only 124 

Cured 69 (56%) 

Relieved* 40 (32%) 

Unrelieved* 10 (8%) 

Questionable 5 (4%) 

Treated by massage and surgical removal of foci of 

infection 43 

Cured 38 (85%) 

Relieved b (i 37 c) 

Unrelieved i (2%) 

Over-all percentages 

Treated by massage only 124 

Treated by massage and surgery 45 


Cured 

Relieved t 

Unrclievedf 

Questionable 

* Surgerj- advised in 13. 
t Surgery refused in 13. 


107 (63%) 
46 (27%) 
1 1 (7%) 
5 (3%) 


When we combine the results obtained in the 
124 patients who were treated by massage 
alone with the forty-five patients who were 
also subjected to surgical removal of their foci 
of infection, we find that of the entire 169 
patients 107 (63 per cent) were cured, forty-six 
.(27 per cent) were relieved to the extent that 
they believed ' further treatment was not 



1 16 


rhielc — Coccygocl^'tiia 


required, eleven (6.5 per cent) were unrelieved 
and in five (3 per cent) the results ^Yere ques- 
tionable. (Table ii.) In two (i per cent) no 
treatment was given. Surgical treatment was 
advised but refused by thirteen patients who 
had obtained insufficient relief from massage. 
It is interesting to note that in five of the six 
patients in whom there was no improvement 
lawsuits were pending against department 
stores where injurious falls were alleged to have 
occurred. 

SUMMARY 

Coccygodynia is caused by direct trauma and 
by muscle spasm secondary to focal infection. 
It may be cured by massage of the spastic 
muscles together with removal of foci of infec- 
tion when necessarj'^ or desirable. In rare cases 
of osteoporosis, osteomyelitis or fracture coc- 
cygectomy may be necessary. 

REFERENCES 

1. Thiele, George H. Tonic sp.ism of tlie levator ani, 

coccygeus and piriformis muscles: relationship to 
coccygodynia and pain in the region of the hip 
and down the leg. Tr. Am. Prod. Soc., 37: 145-- 

155, 1936- 

2. Thiele, George H. The management of the 

patient with painful coccy.x. Kansas City M. J., 
13: 21-22, 1937. 


3. Thiele, George M. Coccygodynia and pain in the 

superior gluteal region and down the back of 
the thigh. J. A. M. A., 109: 1271-1274, 1937. 

4. Thiele, George M. The painful coccy.x: its cause 

and treatment. Kan.sas City M. J., 24: 16-20, 
1948. 

5. IIamsa, \Vm. R. Coccygodynia: a study of the end 

results of treatment. J. Iowa M. Soc., 27: 154, 
> 937 . 

6. Drceck, Chas. j. Coccygodynia. Its diagnosis and 

treatment. Illinois M. J., 79: 256-259, 1941. 

7. I loiiART, M. 1 1 . Manipulative treatment of eoc- 

cygodynia. 5 . Clin. North America, 17: 579-583, 
' 937 . 

8. Kleckni;u, Martin S. Coccygodynia. The prc.sent 

day interpretation and treatment. Tr. Am. Tract. 
Soc., 34: 100, 1933. 

9. King, George S. The treatment of coccygodynia. 

Inclusi. Med., 10: 15, 1941. 

10. Waters, Edw. G. A consideration of the types and 

treatment of coccygodynia. Am. J. Obst. cY' 
Gynec., 33: 529, 1937. 

11. Baastrvp, C. 1. Rontgenbchandlung von Kokzj'- 

godynic. Strablcnthcrapic, 56: 184, 1936. 

12. Key, j. a. Operative treatment of coccygodynia. 

J. Done &■ Joint Sing., 19: 759-764, 1937. 

13. Simpson, Sir J. Y. Coccygodynia and diseases and 

deformities of the coccy.x. A'/. Times Cr Gaz., 40: 
1031, 1859. 

14. Granet, Emil. Proctalgias: coccygodynia. Arn. J. 

Digest. Dis., 13: 330-331. '946. 

15. Wilkinson, Walter R. Coccygodynia. South. 

Surgeon, 13: 280, 1947. 




American Journal of Surgery 



LOW BACK AND RECTAL PAIN FROM AN ORTHOPEDIC 
AND PROCTOLOGIC VIEWPOINT* 

WITH A REVIEW OF 180 CASES 

Saul Schapiro, m.d. 

Brooklyn, New York 


T he management of low back pain con- 
tinues to be a problem to many physi- 
cians, particularly the orthopedist and 
proctologist. The orthopedist occasionally is 
confronted with the realization that his treat- 
ment of some low back pain is not satisfactory. 
Similarly the obscure rectal pain especially that 
associated with low back pain is at times a 
problem to the proctologist notably when the 
symptoms persist after the removal of rectal 
disorder. 

This material is presented as an orthopedic- 
proctologic problem because the proctologist 
often sees orthopedic conditions with ostensible 
rectal symptoms while the orthopedist sees 
proctologic disorders because of suggestive 
orthopedic symptoms. 

It is the purpose of this paper (i) to throw 
some further light on the obscure rectal pain 
and the low backache; (2) to show a relation- 
ship between these two types of pain; (3) to 
attract attention to another symptom com- 
plex, the “Thiele Syndrome” and (4) to 
describe some conditions demonstrable through 
a routine proctologic-orthopedic and radio- 
graphic examination. 

Pain referred to the rectum or the low back 
may be due to diseases of other systems than 
the terminal bowel and lower spine. However, 
the material presented here concerns itself with 
pain only in or about the rectum and low back 
which involves the rectum or the sacrum and 
coccyx, their joints, their attached muscles and 
ligaments, their associated nerves and the 
gluteal region. 

The study of the material in this article has 
for its basis certain established anatomic facts. 
Yeoman^ in 1928 published the first reference 
to the piriformis muscle as a cause of sciatic 
pain. He described the piriformis muscle as 
lying between the lumbosacral trunk and the 
lower margin of the sacro-iliac joint. He 
attributed 36 per cent of his cases of sciatica to 
* From the Division of Proctology, 


sacroiliac arthritis. The arthritis affected the 
anterior sacroiliac ligament and piriformis 
muscles; the latter in turn affected the sciatic 
nerve. In 1934 Freiberg and Vinke- stated that 
part of the piriformis arises from the sacroiliac 
joint and bridges it. Therefore, the muscle 
should become irritated and react by spasm as 
a result of disease in this joint. They further 
stated that the sciatic nerve passes through the 
fibers of the piriformis in 10 per cent of ca- 
davers and, therefore, pressure of the muscle 
would cause pain. 

Hershey’ dissected the anterior sacroiliac 
regions of sixty-four cadavers. He found the 
piriformis muscle to be medial to the lumbo- 
sacral nerve trunk and never between the 
trunk and the joint. He also found that the 
lumbosacral trunk was in direct contact with 
the sacroiliac joint in its lower third. The hyper- 
trophic arthritis of this joint which was present 
in 25 per cent of the cadavers he considered 
likely to produce direct irritation of the lumbo- 
sacral trunk with severe muscle spasm. 

The coccj^x has some important relation- 
ships. (Fig. 4.) Attached to it anteriorly are the 
levator ani and coccygeus muscles, the sacro- 
spinous ligament and parts of the sacrotuberous 
ligament; attached laterally is the gluteus 
maximus muscle and at the tip are the anal 
sphincter and anococcygeal tendon. The sacro- 
coccygeal articulation has many ligaments and 
a fibrocartilaginous disc interposed. The an- 
terior coccygeal surface is in close relationship 
to the posterior rectal wall. Both sympathetic 
nerve trunks communicate with each sacral 
nerve and the coccygeal nerve forming an 
e.xtensive nerve plexus on the precoccygeal 
surface. Filaments from this plexus pass to the 
levator, coccygeus, gluteus maximus and the 
sphincter ani muscles, and the sacrococcygeal 
joint. Thus it is seen that the structures \vhich 
constitute the sacral, coccygeal and rectal 
regions are richly supplied by the sacral and 
Jewish Hospital of Brooklyn, N. Y. 


January, igso 


17 



Schapiro — Low Back and Rectal Pain 


■ ii8 



Fig. I. Typical spot x-rny of sacrum and coccyx with 
an examining finger in the rectum showing the 
anatomic relationships and tlic structures wliich can 
be reached: S.i to S.,, sacral segments; C.i to C.2, 
coccygeal segments; P., piriformis muscle fibers; C., 
eoccygeus muscle fibers; L. A., levator ani; II. .S., ex- 
ternal sphincter fibers; G. M., gluteus maximus muscle 
fibers; S. T., sacrotuberous ligament; S. S., sacro- 
spinous ligament and A. C., anococcygeal ligament. 


coccygeal nerve ple.xuses. These anatomic rela- 
tionships and the extensive lymphatic distribu- 
tion explain the variety of symptoms and their 
implications. 

Thiele® in 1936 reported his studies on the 
tonic spasm of the levator ani, coccygeus and 
piriformis muscle as an important factor in low 
back and rectal pain. His observations of the be- 
havior of these muscles and his sound anatomic 
explanations have been responsible for attract- 
ing attention to this hitherto neglected relation- 
ship and for stimulating this study. In 1937® 
Thiele again' reported eighty cases of coccygo- 
dynia having tonic spasm of the piriformis, 
coccygeus and levator ani muscles. Rectal 
massage of these muscles resulted in the cure of 
60 per cent of his patients, improvement in 
33-7 per ce'nt and failure in only 6.3 per cent. 
Thiele s obsen^ation on cadavers supports the 
hypothesis that spasm of the piriformis and 
coccygeous muscles causes pressure on the 


sciatic and the superior gluteiil nerves. He 
removed the sciatic nerve and inserted his 
index finger in its place. The thigh was then 
internally rotated causing his finger to be 
tighth' squeezed between the piriformis muscle 
and the sacrospinous ligament. Thiele also 
states that spasm of the levator ani and 
coccygeous muscles exerts traction on the 
coccyx. Since Thiele was the first to attract 
attention to the tonic spasm of the levator ani, 
coccygeous and piriformis muscle and since he 
described its clinical importance and its treat- 
ment, the author chooses to refer to it as the 
“'riiicle Syndrome.” 

In 1936 Hill" reported a study of thirty-one 
patients who complained of high, obscure rectal 
pain which ultimately proved to be due to 
sacroiliac strain. The pain in all these patients 
was largely or complete^; alleviated by ortho- 
pedic measures. Interestingly in twentj' of 
Hill’s cases of sacroiliac strain there were 
thirteen patients with anorectal disease which 
required surgery. I lowever, after the surgery 
was performed, a cure of the high rectal pain 
was obtained only after the institution of 
appropriate orthopedic measures. 

The belief prevails that the piriformis muscle 
and the sacral region are difficult to palpate 
through the rectum. Figure one shows the 
height to which a normal finger can reach and 
the anatomic relationships thereof. Shordania** 
identifies the muscle during external rotation 
of the e.\tended thigh while Smrth-Petersen'® 
states that the sacroiliac joint maj' be palpated 
through the rectum to determine sacroiliac 
tenderness. 

Essentially then the following fundamentals 
must be considered. The external sphincter 
anococcygeal ligament, levator ani, coccygeus, 
sacrospinous ligament, piriformis, sacrotuber- 
ous ligament and gluteus maximus are attached 
to the cocej'x and sacrum, the piriformis also 
bridging the sacroiliac joints. (Fig. i.) Any 
involvement of these bones and their joints 
affects their attached muscles and related 
nerves causing tenderness, spasm and reflex 
sj'mptoms. Converse^' anj" involvement of 
these muscles or nerves and Rmiphatics from 
rectal conditions might conceivably have their 
physical effect on attached bone and cause the 
resultant sj-mptoms. 

The aforementioned fundamentals form the 
basis of the ensuing report and 180 cases are 
presented in six groups as follows: (i) origi- 

American Journal of Surgery 




Schapiro — ^Low Back and Rectal Pain 


119 


natingin ligamentous sacroiliac strain seventeen 
cases; (2) associated with coccygodynia forty- 
five cases; (3) associated with demonstrable 
disorder in the sacrococcygeal region fifty-nine 
cases; (4) without demonstrable rectal or sacro- 
coccygeal disturbance twenty-two cases; (5) 
with demonstrable rectal disease sixteen cases 
and (6) following rectal surgery twenty-one 
cases. 

The plan of study was as follows: All patients 
complaining of pain in the low back at the end 
of the spine and gluteal regions with or without 
symptoms referrable to the rectum were 
examined routinely as follows: (1) Digital 
examination: intrarectal palpation; palpation 
of all pararectal muscles, presacral and coc- 
cygeal regions and the sacroiliac joints; 
bi-digital examination of coccyx; (2) proc- 
toscopy; (3) x-ray of coccyx and sacrum and 
their joints with a special spot x-ray technic and 
(4) orthopedic consultations. 

LOW BACK AND RECTAL PAIN ORIGINATING IN 
LIGAMENTOUS SACROILIAC STRAIN 

There were seventeen patients in this group 
complaining of rectal pain which eventuallj^ 
proved to be due to ligamentous sacroiliac 
strain. (Postural strain.) The diagnosis of 
sacroiliac strain was ultimately established by 
adherence to the accepted orthopedic pro- 
cedures such as x-rays, Gaenslen’s sign,® 
lumbar spasm, pelvic percussion test, Gold- 
thwaite test® and the finding of tenderness over 
the sacroiliac joint*® by palpation through the 
rectum. 

Symptoms. The s^’^mptoms in these patients 
varied as follows. There was pain high in the 
rectum, low in the rectum, burning, gnaw- 
ing pain, pain on sitting and walking, and pain 
on; defecation or relief of pain on defecation. 

Most patients had difficulty in localizing 
the back pain. It was either in the center of the 
back, to one side, both sides, in the gluteal 
regions or down the thighs while others did not 
know which was worse, the back pain or the 
rectal pain. 

Exammation. The examination through the 
rectum revealed tenderness and occasional 
spasm of one or both of the piriformis muscles 
usually on the involved side. The spasm could 
be aggravated by. internally rotating the leg. 
With this there was associated various spastic 
involvement of the coccygeus and levator ani 
muscles. In these cases irritation of the sacro- 
iliac joint due to strain on the sacrospinous and 

January^, ig^o 


sacrotuberous ligament results in spasm of the 
piriformis muscle. This spasm is e.xtended to 
the coccygeus and levator muscles thereby 
producing the pain referred to the rectal region 
and coccyx. Rectal disorder was absent in all 
but two of these cases and in these no relief was 
obtained after removal of the rectal disturb- 
ance. The x-raj'S were negative in all seventeen 
cases. 

Treatment. Treatment consisted at first of 
digital massage to the piriformis, coccygeus and 
levator ani muscles through the rectum using 
Thiele’s technic. All patients obtained relief in 
varying degrees. However, a complete cure 
was effected only after orthopedic measures 
were instituted sueh as enforced rest or occa- 
sional injections of 10 cc. of i per cent novocain 
into the piriformis muscle as it traverses the 
gluteal region. 

Case History. A thirty-fiv'c year old housewife 
complained for fifteen months of an irritating recta! 
pain without definite localization associated with 
pain in lower back, left buttocks and left thigh. 
Eight months after the onset of these symptoms 
she had a fissurectomy but the symptoms persisted. 
It was later learned that her symptoms started 
when she moved her furniture into another apart- 
ment. Orthopedic examination showed tenderness 
over the left sacroiliac ligaments and tenderness 
over the gluteal nerves in the left buttocks. 
Goldthwaite’s test was positive. X-rays of the 
pelvic bones were negative. There was tenderness 
of the left piriformis muscle and spasm of the 
levator ani coccygeus muscles. Rectal massage gave 
temporary relief. A diagnosis of left sacroiliac 
strain was made and she was cured with orthopedic 
measures. 

LOW BACK AND RECTAL PAIN ASSOCIATED WITH 
COCCYGODYNIA (NEURALGIA, NEURITIS) 

The patients placed in this group of neuralgic 
coccygodynias were those whose x-raj' studies 
of the coccyx and sacrum were negative and 
tvhose pain was elicited around the coccyx by 
the bi-digital rectal examination. Cases of 
recent acute injurj;- such as fractures and dis- 
locations were excluded as were cases believed 
to be due to neurosis. Forty-five cases were 
encountered in this group. 

Symptoms. The predominant symptom was 
pain at the end of the spine. This pain varied in 
description and distribution about the coccjlx 
on sitting and rising; when lying down; over 
the gluteal region; in the thigh or thighs; on 
defecation and pressure or heaviness in the 



120 


Schapiro — ^Low Back and Rectal Pain 


rectum. It varied from a dull ache to a severe, 
boring pain. It lasted from several days to 
three years. There was a history of some casual 
trauma in manj’- of these cases. These injuries 
were light falls, instrumental deliveries, bounc- 
ing about in a truck or motorcycle and fecal 
impactions. 

Table i 

CONDITIONS INVOLVING SACROCOCCYGEAL BONES AND 
THEIR JOINTS 



No. of 
Cases 

Per cent 

Anterior cicviution or angulation of 1 

i8 

30.50 

. 8.47 
5.08 
6.77 
3-39 
3-39 

I -69 
3-39 

1 .69 
8.47 

1.69 

15.25 

3-39 

1.69 

1 .69 

1 .69 

1 .69 

Left deviation of coccyx, 1 

£ 

Right deviation of coccyx 


Posterior displacement of coccyx i 

A 


2 


2 

Separation of coccygeal bones 

I 

Congenital deformity of coccyx 

2 

Congenital absence of distal coccyx. . 
Arthritis of sncro-ilinc region 

1 

e 

Boney overgrowth of distal end of 

X 

Arthritis of sacro-coccygeal articula- 
tion 

0 


2 


I 

Ostenehondrosarcoma 

I 

Fibrosarcoma 

I 


I 



1 59 

100.00 



Spina bifida occulta was associated with nine of the 
above cases. 


Examination. By means of bi-digital rectal 
examination all patients manifested varying 
degrees of tenderness over the coccyx or in the 
structures lateral to it. Manipulation of the 
sacrococcygeal joint usually caused some pain 
while pressure on the ventral sacrococcygeal 
surface caused exquisite pain in some. On rectal 
examination the tip of the finger would feel 
with lateroposterior pressure the levator ani, 
coccygeus and piriformis muscles to be either 
spastic, tender or both in many cases. Tender- 
ness was often present in the gluteal muscles 
over the distribution of the superior gluteal 
nerve. The variety of pains can be attributed 
to the pinching of the perisacrococcygeal tissues 
from the contraction of the muscles and 
tendons, stool evacuations, sitting or mis- 
referred reflex pain. 

Treatment. Treatment consisted of the daily 


use of a rectal dilator by the patient to relax 
the external sphincter and levator muscles. 
This was followed by rectal massage to the 
involved pararectal muscles. In those patients 
whose muscles were very tender intrarectal 
diathermy treatment made the massages 
easier. Treatments were given twice weekly, 
the number in this series varying from two to 
twelve treatments. This treatment resulted in 
64 per cent cures, 31 per cent improved and 
5 per cent unimproved. Pericoccygeal injec- 
tions" of anesthetic solutions, alcohol, quinine, 
etc., gave temporary relief in only a few 
patients. 

Case History. A thirty-five year old housewife 
complained of throbbing pain over the sacrum and 
down both thighs for fourteen months. She was 
treated for sacroiliac arthritis without any relief. 
During the later months she was unable to lie or 
sit comfortably. There was pain up in the rectum 
which was aggravated during bowel movement. 
Rectal examination revealed three hypertrophied 
anal papillae with a eryptitis which when removed 
failed to relieve the patient. Later examination 
revealed a very tender mobile coccyx associated 
with tenderness of the coccygeus and both levator 
ani muscles. X-ray was negative and a diagnosis of 
coccygeal neuritis was made. Injections of anes- 
thetics in oil did not help her. Treatment consisted 
of massage of the pararectal muscles and after 
twelve treatments the patient was discharged as 
cured. 

LOW BACK AND RECTAL PAIN ASSOCIATED WITH 
DEMONSTRABLE DISORDER IN THE 
SACROCOCCYGEAL REGION 

Acute injuries or acute disease of the sacrum 
and cocej-x are not included in this group. The 
cases consist of those patients with indefinite 
chronic low back and rectal symptoms which 
were undiagnosed for periods ranging from 
several weeks to nine years. There were fifty- 
nine such patients. (Table i.) Thirty-three of 
these cases consisted of mechanical changes 
in the coccyx and are probably the only type of 
cases which can be considered true coccygo- 
dynias. I prefer to think of coccygodynia merely 
as a symptom of pain in a specific disease 
occurring in the coccyx region’"’" 

The five tumors in this group were first 
detected by digital examination through the 
rectum. Whittaker" reported nineteen cases of 
presacral tumors which also were first recog- 
nized this way. 

Symptoms. The symptoms in this group 
with the mechanical changes of the coccyx 

American Journal of Surgery 



m- 


Schapiro — Low Back and Rectal Pain 




Fig. 2. Spot cone x-rays of cases from Group iii; films i to 7 and 9, anterior displacements of 
coccyx; 8 and 11, posterior displacements of coccyx; 10, congenital absence of coccyx; 12 to 14, 
anterior displacements with fused coccyx; 15 to 17, fractures of coccyx; 18, sacrococcygeal arth- 
ritis; 19, boney overgrowth of distal sacrum; 20, separation of coecyx with anterior displacement; 
2j, chordoma of sacrum; 22, fused coccyx, anterior displacement; 23, Marie-Strumpell arthritis; 
24, displacement of distal coccjtc to left. 


Januarv, /Q50 




122 


Schapiro — Low Back and Rectal Pain 



Fig. 3. Tumors involving the sacrum and coccyx; 
I, 2 and 3 are specimens removed at operation with 
their corresponding x-rays of sacrum and coccyx 
taken before operation showing destruction of tlicsc 
bones. Diagnosis was first made by digital examina- 
tion through the rectum. 

(traumatic coccygodynia) such as deviations, 
separations, angulations, fractures, etc., were 
similar to the second group of neuralgic 
coccygodynias and from which they had to be 
differentiated. The sjTOptoms produced by 
tumors involving the sacrum and coccyx varied 
greatly dependent upon nerve encroachment 
from the expanding grotvth. Pain occurred in 
the^ lower part of the spine, pelvis or sciatic 
re^on associated with progressive constipation 
an a ull ache or pain in the rectum; weakness 


and numbness of buttocks and thighs; and 
rectal incontinence. 

Case Histories, i. A nineteen year old girl was 
treated in two hospitals for saeroiliac strain and 
sciatic neuritis. Slie had stabbing pain in the right 
hip, buttock and leg. She continually complained 
of rectal pain whicli ultimately was found to be 
caused by extreme spasm of the levator, coccygcus 
and piriformis muscles. These spastic muscles were 
found to be more tender on tlic same side as her 
back pain. X-rays of the coccyx previously had 
been considered negative. Our spot x-raj' diagnosis 
was lliat of a marked fracture displacement at the 
sacrococcygeal joint. (Fig. 2, seventeen.) She 
finally recalled having fallen from a bicj'cle six 
years before. Excision of the coccyx effected an 
immediate cure. 

2. A doctor had low back pain for many years 
which later became associated with rectal pain. 
A spina bifida was blamed for these symptoms. On 
rectal examination the coccygeus and piriformis 
muscles were very tender. Spot x-rays showed a 
posterior displacement and separation between 
his second and third coccygeal segments. (Fig. 2, 
eleven.) One rectal massage relieved him. The 
manipulation apparently replaced the displacement 
even after long-standing fixation.’” 

3. A forty year old housewife was ojjerated upon 
twice for rectal disorder. She continued to complain 
of pain upon sitting and walking. Bowel movements 
gave her a soreness in the rectum and aggravated 
the back pain. A posterior dislocation of the coccyx 
was found by a spot x-raj'. Both coccj'gcus muscles 
were tender. A history of a fall was then recalled. 
Bi-digital reduction of the coccyx and five rectal 
muscle' massages relieved her completely. 

4. A forty-three year old man had an excision of 
a nucleus pulposus protrusion which had resulted 
from an accident seven years previously. His severe 
pain of so-called sciatica was somewhat relieved 
after the operation but for the year following he 
complained bitterlj' of constant pain at the base of 
his spine. There was marked tenderness and spasm 
of the piriformis and coccygeus muscles. His relief 
after the second massage together with diathermy 
was spectacular and after five treatments he was 
relieved. Two years later he was still symptomless. 

5. A sixty-five year old woman had prolapsing 
hemorrhoids removed which did not relieve a back 
pain of four years’ duration. Her rectal pain per- 
sisted and her back pain became more intense 
especially over the coccyx. The coccygeus muscles 
were tender. X-ray showed a posterior deviation 
at the sacrococcygeum and irregularity of the 
joint space. (Fig. 2, eight.) Manipulation of the 
coccyx’”-'” and seven muscle massages relieved her. 

6. A fifty-eight year old female complained of 
low back and rectal pain for six months. She had 
been treated for lumbo-aVthritis without relief. 

American Journal of Surgery 


Schapiro — Low Back and Rectal Pain 


123 



Fig. 4. Schematic view into pelvis from in front and above showing the anatomic relationship 
of the structures which enter into the mechanism of transmitted symptoms between the rectum 
and low back; note that the coccygeal plexus lies on the coccygeus muscle. It gives rise to ano- 
coccygeal nerves (not shown) which pierce the sacrotuberous ligament to supply the skin in the 
region of the coccyx. The fourth sacral nerve via the perineal branch (not shown) pierces the 
coccygeus muscle to supply the external sphincter muscle and the skin between the anus and 
coccyx. X indicates the height a finger can reach when inserted into the rectum. 


She was given anesthetic injections for coccygo- 
dynia. A fistulectomy was also performed. Finally, 
two years after the onset of her symptoms a rectal 
examination revealed a presacral mass and an 
x-ray showed an absorbed sacrum and coccyx. At 
operation a large chondrosarcoma was found 
involving the sacrum and coccyx. (Fig. 3, three.) 

Most of the patients in this group had x-rays 
of the pelvic bones which were considered nega- 
tive. Some did not have x-rays until late in the 
course of their illness. (Case 6.) It is our belief 
that x-rays of the sacrum and coccyx must be 
taken separately for detail and not as a unit 
with the pelvis. Better detail is obtained by the 
use of a special spot cone x-ray technic. A 
5-inch cone is focused at a distance of 30 inches 
so that the ischial tuberosities, sacral curve and 
greater sciatic notch form the borders in the 
lateral view. The anteroposterior view should 
be taken with the tube tilted caudad at 25 
degrees to avoid overlapping of the pubic bones. 
In order to demonstrate by x-ray the lower 

January, 1950 


anterior sacroiliac joint Hershey® places the 
x-ray tube at a so-called negative of 20 degrees 
from the perpendicular and toward the head. 
He states that hypertrophic lipping of the lower 
sacroiliac joint can be determined by antero- 
posterior x-rays. 

In discussions with roentgenologists early in 
this study some of the deviations labelled 
abnormal by this writer were considered within 
normal limits by them. For example, in Case i 
the x-ray report was as follows: “There is 
rather an acute angulation between the first 
and next three coccygeal segments. It is 
probably irrelevant.” Our diagnosis confirmed 
at operation was fracture dislocation. In our 
experience we consider certain .x-ray findings 
abnormal when found associated with low back 
pain, rectal pain and spasm of the pelvic 
muscles. These x-ray findings are angulation 
at the joints of sacrum and coccjtc either 
anteriorl}'-, posteriorly or laterally; anj-^ single 
separation or fusion of these joints; any extreme 



124 


Schapiro — ^Low Back and Rectal Pain 


flattening of the sacral curve or anj' extreme 
narrowing of the greater sciatic notch. In these 
cases we usually consider the bony changes as 
the causative factors in their effect on the 
attached muscles, nerves and ligaments. 

The treatment of the meclianicai coccygo- 
dynias in this group consisted of manipulation 
to the coccyx and massage to the pararectal 
muscles. Two posterior dislocations and one 
fracture of the coccyx were cured by coc- 
cygectomy. The tumors were treated by 
surgical excision including the involved bone 
followed by x-ray therapy. 

RECTAL PAIN AND LOW BACK PAIN WITHOUT 
EITHER RECTAL DISORDER OR INVOLVEMENT 
OF THE PELVIC BONES OR JOINTS 

(idiopathic, neurosis) 

In this group of twenty-two cases the pa- 
tients had indefinite, obscure, chronic rectal 
pain of varying degrees associated with diffuse 
low back aches without any demonstrable 
rectal lesions or low spine changes. They were 
considered neurotics and went about un- 
diagnosed and unrelieved. In 1935 Buie and 
Brust'® reported that out of 100 patients with 
high rectal pain the cause was undetermined in 
71 per cent of them but they considered 52 per 
cent due to some form of neurosis and in onlj' 
3 per cent was a diagnosis made of disease 
of the pelvic bones and joints. It is quite 
possible that if their patients were restudied 
in the light of our newer understanding, many 
of these patients might be relieved of their 
distress. 

Syviptoms. These .patients complained of 
pressure, heaviness or occasional sharp pains 
high in the rectum and burning sensation or 
pain on defecation. Most of these patients had 
vague pains variously distributed over the low 
back and gluteal regions either upon lying, 
standing or walking. 

Examination. There were various degrees 
of tenderness over the gluteal regions. On 
rectal examination all had either tenderness, 
spasm or both in the pelvic muscles. The x-rays 
of the saerum and coccyx of these patients were 
negative. 

Treatment. Upon treatment by rectal mas- 
sage to these muscles sixteen of the patients 
were completely cured, three were considerably 
relieved, one required continued treatment and 
two remained unrelieved. 

ft is difficult to explain the cause of the 
syndrome and the relief obtained by the treat- 


ment in this group. A myositis or myofascitis 
of the pelvic muscles from a focus of infection 
or from faulty lymphatic drainage is a likely 
possibility. An inflammatory reaction in these 
muscles is produced followed by irritation, 
tenderness and spasm. Treatment b}"^ massage 
could conceivably break up any adhesions 
which have formed and give subsequent relief. 

Case History. A thirty-six year old male com- 
plained of a constant aching pain of five years’ 
duration in both buttocks on bending and sitting. 
The symptoms disappeared after a tonsil operation 
but a year later the symptoms recurred associated 
with straining, uncomfortable bowel movements. 
He had been treated as a neurotic. Rectal examina- 
tion revealed marked bilateral levator ani piriformis 
spasm with moderate tenderness in both gluteal 
regions. X-ray of pelvis was negative and there was 
no rectal disorder. After six rectal massages and 
intrarcctal diathermy all the symptoms disappeared 
and nine months later he was symptom-free. 

RECTAL PAIN AND LOW BACK PAIN WITH RECTAL 
DISTURBANCE ONLY 

This group comprised sixteen cases in which 
there was marked spasm, tenderness or both 
of the external sphincter, levator ani and 
coccygeus muscles associated with definite 
disease of the anorectum which was believed to 
be the eausative factor.^'' These patients 
described vague pains in the coccyx and supra- 
gluteal regions which were concomitant with 
their rectal symptoms. The rectal symptoms 
were a dull ache or a sensation of fullness in the 
rectum or a throbbing pain aggravated on 
defecation. After rectal surgerj'^ was performed, 
nine patients were completely cured and seven 
continued to complain of pain up in the rectum 
for a considerable time after the wound healed. 
Subsequent examination of the latter patients 
failed to reveal any other cause for the per- 
sistent muscle spasm. Three to eight massages 
to these museles rapidly effected a cure. It is 
believed that in these patients the muscle spasm 
was due to the rectal condition which probably 
produced a myositis, irritation and spasm of 
the muscles via the lymphatics and finally 
resulted in symptoms simulating coccygodynia 
or sciatica. In the seven persistent cases the 
fixed myositis required additional treatment 
of muscle massage after the rectal surgery. 

Case History. A fifty-two year old male for 
nine years had low rectal pain on defecation with a 
constant burning sensation in the buttocks which 
became painful when sitting. Orthopedic, x-ray and 

American Journal of Surgery 



Schapiro — Low Back and Rectal Pain 


125 


sigmoidoscopic examinations were negative and 
rectal examination revealed a markedly spastic 
external sphincter muscle with tenderness of both 
levators and coccygeus muscles. The coccygeal area 
was negative. Anoscopic examination revealed four 
large anal papillae with anal cryptitis. There was 
moderate tenderness on deep pressure over the 
gluteal muscles. Rectal surgery was performed but 
the symptoms persisted for three months after the 
wound had healed. After seven rectal muscle 
massages he recovered. 

RECTAL PAIN AND LOW BACK PAIN FOLLOWING 
RECTAL SURGERY 

In this group of twenty-one patients there 
was no history of back pain or knowledge of 
any rectal muscle spasm prior to rectal surgery. 
Following rectal surgery these patients had a 
severe postoperative course with painful bowel 
movements and pain in the rectum upon 
sitting, standing and when lying down, with 
pain over the coccygeal and gluteal regions. 
Even after the rectal wound had healed and 
for some time thereafter the aching pain in the 
rectum and gluteal regions persisted. Ortho- 
pedic, proctoscopic and x-ray examinations 
were negative. Rectal examination revealed 
various combinations of spastic and tender 
e.\ternal sphincter, levator ani, coccygeus and 
piriformis muscles. It is possible that these 
symptoms resulted from either a subconscious 
effort by the patient to elevate the anus to 
reduce the pain when sitting thereby producing 
a spasm of the levator and coccygeus muscles; 
because of the fear of painful bowel movements 
the patient withholds passage of the stool 
thereby causing spasm of these muscles or 
there could be some inflammatory reaction 
following the rectal surgery which spreads 
through the lymphatics-' involving the pelvic 
fascia and muscles. 

Although the rectal mucosa is regarded as 
being insensitive, the rectal wall undoubtedly 
has an important sensorj" supply. According 
to the researches of Learmonth-^ the normal 
sensations of physiologic distention pass cen- 
trally via the parasympathetic nerv^es whereas 
painful sensations due to excessive spasm or 
distention pass along the hj^pogastric nerve 
via the afferent pathway. The pain over the 
sacrococcygeal and gluteal regions in this group 
and the one before are perhaps referred-" and, 
therefore, on examination there is no localized 
pain or tenderness in these regions. 

The treatment consisted of six to twelve mas- 

Januaw, ig;o 


sages to the involved muscles through the 
rectum. There was complete recovery in all of 
these patients. 

Case History. A female, thirty-six years of age, 
had an ischiorectal abscess incised which was 
followed by a fistulectomy. For two months after 
the wound healed she had an aching pain across the 
back and in the thighs and a constant pressure 
in the rectum. On palpation there was exquisite 
tenderness of all levators, coccygeus and piriformis 
muscles. After three rectal massages she was able 
to sleep. In ten days she returned to work and after 
twelve treatments she was cured and has had no 
recurrence. 

SUMMARY AND CONCLUSION 

1. One hundred eighty cases of rectal and 
low back pain have been presented. Their 
relationship has been explained with particular 
attention to the importance of referred pain. 

2. The cases are classified into six groups 
according to their variable etiology and 
symptomology. 

3. Some basie anatomic facts are presented 
and re-emphasized in support of the syndromes 
which are described. 

4. Attention is invited to the specific symp- 
tom complex which the author designates as 
the “Thiele Syndrome.” 

5. All the groups revealed on rectal examina- 
tion tenderness or spasm of the levator ani, 
coccygeus and piriformis muscles on one or 
both sides. 

6. In the groups representing orthopedic 
conditions the best treatment was obtained by 
orthopedic procedures. In some of these cases, 
especiall3’' the displacements of the coccyx, 
manipulation through the rectum was effective. 

7. In the groups in which no orthopedic 
conditions were demonstrable most of the 
patients were cured and the others relieved b^' 
rectal massage or diathermj'^ or both to the 
levators, cocej’-geus and piriformis muscles. 

8. Regardless of the eause of the muscle 
spasm massage and intrarectal diathermj’' -were 
satisfactory and at times spectacular thera- 
peutic procedures. 

9. A special spot cone x-raj"^ technic for the 
sacrum and coccyo: is advocated as a routine 
in all cases of low back and rectal pain. A 
more liberal viewpoint is advised in the inter- 
pretation of the x-ray plates. 

10. The digital examination of the rectum 
is the most important single diagnostic pro- 



126 


Schapiro — Low Back and Rectal Pain 


cedure for the recognition of lesions about the 
sacrum and cocc30c. 

The author wishes to thank Doctors B. Kovcn, 
T. Kovcn, J. Milgram, S. Bernstein and L. Nelson, 
orthopedists, and Doctors H. Greenfield and 
B. Epstein, radiologists, for their cooperation, time 
and advice which they gave so generously. Especial 
acknowledgement is hereby made of the invaluable 
aid obtained from the textbook, “Pcrinco-pelvic 
Anatomy,” by Dr. Rudolph V. Gorsch. 

REFERENCES 

1. Yeoman, W. The relation of arthritis of the sacro- 

iliac joint to sciatica. Lancet, 2: 1 1 19-1 122, 1928. 

2. Freidero, a. H. and Vinke, T. H. Sciatica and the 

sacro-iliac joint. J. Bone & Joint Surg., i6: 126, 

1934- 

3. Hershev, Charles D. Sacro-iliac joint and pain 

of sciatic radiation, J. A. A'/. A., 122: 983, 1943. 

4. Waters, E. G. A consideration of the tj'pcs and 

treatment of coccygodynia. Am. J. Olst. (f 
Gjmec., 33: 531-535. Waj- 

5. Thiele, George H. Tonic spasm of the levator 

ani, coccygeus and piriformis muscles: relation- 
ship to coccygodynia. Tr. Am. Proc. Soc., 37: 

145-155. 1936- 

6. Thiele, George H. Coccygodynia and pain in the 

superior gluteal region. J, A. M. A., 109: 1271- 

1274. 1937. 

7. Hill, AI. R. Rectal pain in cases of sacroiliac 

strain. Tr. Ain. Proc. Soc., 37: 136-144, 1936. 

8. Shordania, j. F. Die chronische Entzundung des 

Alusculus Piriformis die Piriformitis — als cine 
der Ursaclien von Krcuschmcrzcn bci Frauen. 
Med. Welt, 10: 999, 1936. 

9. Goldwaithe’s sign and Gaensicn’s sign for diagnosis 

of sacro-iliac. Nelson Loosclcaf, P. 183 J. 

10. Smith-Petersen, M. N. and Rogers, W. A. End 

result study of arthrodesis of sacro-iliac joint for 
arthritis. J. Bone if Joint Surg., 8: 1 18, 1926. 

11. Kleckner, Martin S. Coccygodynia; the present 

day interpretation and treatment. Tr. Am. Proc. 
Soc., 34: 100-107, 1933- 

12. Simpson, Sir J. Y. Coccygodynia, and diseases and 

deformities of the coccyx. M. Times &• Gaz., 40: 
1031, 1859. 

13. Drueck, C. j. Coccygodynia: its diagnosis and 

treatment. Illinois M. J., 79: 256-259, 1941. 

14. Whittaker, Lorin D. and Pemberton, John De. 

tumors ventral to the sacrum. Ann. Surg., 107: 
96-106, 1938. 

15. Hobart, M. H. Coccygodynia: end results of 

treatment. 5 . Clin. North America, 17: 579— 583, 

1937- 

16. Duncan, G. A. Painful coccyx. Arch. Surg., 34; 

1088, 1937. 

17. Greenfield, H. and Epstein, B. Personal cooper- 

ation and advice. 

18. Haggart, G. E. Sciatic pain of unknown origin. An 

effective method of treatment. J. Bone &r Joint 
Surg., 20: 851-859, 1938. 

19. Buie and Brust. High rectal pain, an analysis 

i°o cases. Am. J. Digest. Dis., 1 : 591-594, 1934. 

20. w ilkinson, W. R. Coccygodynia: review of liter- 


ature and presentation of cases. South. Surgeon, 

13; 280-293, 1947. 

21. Wi LENSKY, A. O. Osteomyelitis of pelvic girdle. 

Arch. Surg., 37: 371-400, 1938. 

22. Gray, Charles. Causes and treatment of sciatic 

pain. Internal. Ahstr. Surg., 85: 417-441, 1947. 

23. Learmonth, j. R. Contribution to neurophysiology 

of urinary bladder in man. Brain, 54: 147, 1931. 

DISCUSSION OF PAPERS BY DRS. THIELE AND 
SCHAPIRO 

L. J. Johnson (San Jose, Calif.): Discussion of 
coccygodynia at this time seems most timely. One 
often wonders if the urge to write about this 
miserable malady docs not come to our members 
while attending meetings of this or similar societies. 
When we hear Dr. Thiele report the results of a 
busy proctologic practice over a period of fifteen 
years and learn that he has found 169 cases and 
that Dr. Schapiro toiled for an even longer period 
of time and saw 180, it seems apropos to suggest 
that research could be accomplished while this 
convention is in session. 

“Coccygodnia,” as a word, appears to be the 
name selected by the more genteel portion of our 
society; the average man on the street speaks of it 
in much simpler terms. During the meetings of the 
legislature this common expression is often heard. 

I would like to quarrel with this tongue-twisting, 
indefinite and awkward word; both of the previous 
speakers and most writers on the subject apologize 
for its narrow definition. It was a pleasure to hear 
Dr. Kallet report that suggestions arc being offered 
for changes in the nomenclature and I am sure we 
all hope this word becomes deleted and some other 
invented to cover the definition. 

We arc indebted to Drs. Thiele and Schapiro for 
again bringing up the subject of low back pain 
before this society. It is a constant bother to all 
physicians, and there are but few specialties who 
arc not plagued with patients suffering from this 
condition. Certainly the proctologist sees man}' 
cases, and Dr. Schapiro’s plea to join other special- 
ists in its study is timely and definitelj' warranted. 

It is ama-zing to sec how puzzling pain in the 
lower back, cocc3'godynia, coxalgia, etc., has been 
over a period of many years. For over a centurj' 
writers have been reporting treatments, and those 
treatments vary from traction to stretching, from 
injection of nerves to forcible manipulation, to 
fusion of- the sacroiliac joints and lumbosacral 
articulations; section of the piriformis muscles and 
incision of the iliotibial bands by Ober; sub- 
periosteal strippings of the gluteal muscles and 
ligaments, etc., all of which means that no single 
system of treatment has proven satisfactory. 

Anorectal disorders as etiologic factors in pro- 
ducing coccygodynia cannot be overemphasized, 
but the proctologist should be ready to confer with 
the neurologist, orthopedist, gynecologist or urolo- 

American Journal of Surgery' 



Schapiro — Low Back and Rectal Pain 


127 


gist as is indicated by his findings after a complete 
physical examination and a meticulous proctoscopic 
study. 

Dr. Thiele, who is always remembered for his 
excellent study of tonic spasm of the piriformis 
muscle, has fortified his earlier papers by showing 
that true coccygodynia is not the result of piriformis 
muscle spasm but appears with coccygodynia, and 
both conditions arise from the same causes. His 
technic of first removing foci of infection followed 
by repeated gentle massage of the spastic muscles 
has become routine procedure in most proctologic 
clinics. 

Dr. Schapiro has shown a fine series of coccygeal 
deformities and abnormalities, and again let me 
support his advice to confer with other specialists 
when studying patients who complain of low back 
pain and rectal distress. He has incorporated the 
principles of good proctologie care following excel- 
lent spot x-rays and orthopedic consultation and 
has accentuated the need for careful diagnosis. 

George H. Ewell (Madison, Wis.): I am per- 
sonally indebted to Dr. Thiele for bringing this 
subject again to our attention. By applying the 
information obtained in his original contribution to 
my every day practice, I have been able to recog- 
nize and treat with entirely satisfactory results an 
ever increasing number of such cases, many of 
whom had been diagnosed as psychoneurotics. 

I have discussed this subject personally with 
Dr. Thiele on several occasions and I am sure that 
we are both seeing arid discussing the same funda- 
mental condition. We may differ somewhat con- 
cerning details. For the record department in the 
Clinic I have coined the term “the levator syn- 
drome.” The majority of the cases are “pattern 
cases,” yet occasionally they may exhibit rather 
marked variations. 

These cases are referred to our department 
usually because of “pain in the rectum.” Upon 
questioning the patient they will locate the pain or 
ache to one or the other side of the sacrum. I know 
of no pain of which patients complain that will be 
so definitely located on the exterior surface corre- 
sponding to the area of tenderness which can be 
found in the levator muscle, and no group of condi- 
tions in which the results of treatment are more 
uniformly satisfactory. 

The majority of patients are women and in my 
experience 95 per cent have their pain on the left 
side, which commonly radiates into the buttock or 
thigh. Only in rare instances is it influenced bj'^ the 
act of defecation. Many patients may sit with com- 
fort on a hard flat seat but will promptly develop 
pain when sitting on a cushion or an upholstered 
chair. 

Pathologically I believe the condition is due to a 
localized area of myositis with resultant spasm. 
Such a concept, however, is somewhat difficult to 
follow since in so many instances only the left side 

January, /950 


is involved, and in my experience there is rarely 
a recurrence following adequate treatment. 1 
believe indirect trauma is a definite etiologic 
factor. I do not know what role anal disease or 
infection play in some of these cases. 

Since I do both urology and proctology, I should 
like to comment on the relation of chronic pros- 
tatitis as an etiologic factor. I am of the opinion 
that only in rare instances is a chronic prostatitis 
a causative agent. 

Chronic prostatitis is a common condition and 
therefore we should see more cases of the condition 
under discussion in men. In those cases we have 
seen less than i per cent showed a ehronic pros- 
tatitis. We have had sev'eral men referred to us 
because of vague pains in and about the pelvis, 
perineum and sacral region, which had been 
attributed to chronic prostatitis: these patients had 
been treated over a long period of time with no 
relief. Examination revealed no evidenee of chronic 
prostatitis, but did on many occasions disclose the 
typical findings of the “levator syndrome” and 
in most cases relief was promptly obtained by 
massage of the levator. 

I also believe that this same pathologic process 
in the levator is responsible for the condition 
referred to as “proctalgia fugax.” I have had 
several patients, one of whom was a man, who gave 
the typical history of such attacks. The attacks 
were followed by vasomotor reactions and “medical 
shock.” Examinations in these cases revealed the 
tender areas in the levator, in one case on the right 
side. Massage of the areas would reproduce the 
identical pain or typical attacks. All patients have 
been completely relieved by massage. In some 
manner we need to obtain pathologic examinations 
in this group of cases. 

George H. Thiele (Kansas City, Mo.): My 
purpose today has been to present the clinical 
picture of coccygodynia and to discuss its causes. 
You will remember that I confined my remarks to 
the subject of coccygodynia except to mention 
bricflj’- the relationship between spasm of the 
piriformis muscle and pain in the superior gluteal 
region and down the back of the thigh. Piriformis 
spasm often causes low backache. Later on 1 hope 
to publish a paper on this subject. Many of my 
patients with low backache and sciatica (with or 
without coccygodynia) have already been seen 
by the orthopedist or are seen by him at my 
request. 

I wish to thank Dr. Schapiro for his very inter- 
esting and informative paper. He has considered 
the etiology of these symptoms in a somewhat 
different manner than I have; and I believe that if 
we all work together, we will reach some valuable 
conclusions. I wish to add that there has been no 
collusion between Dr. Schapiro and mj'self as we 
had not seen each other’s papers. 



128 


Schaplro — Low Back and Rectal Pain 


Doctor Ewell’s remarks arc very significant 
inasmuch as he has discussed coccygodynia from 
the standpoints of both the urologist and the 
proctologist. He reported that in his experience 
prostatitis was the causative factor in less than 
I per cent of cases. I found two cases in 169, so we 
are In agreement. 

Saul Schapiko (closing): I want to thank Dr. 
Thiele for his kind remarks, 1 also want to thank 
him for calling to my attention this syndrome 
complex so many years ago, approximately four- 


teen years, during which time I was able to accumu- 
late my 180 cases. 

In presenting the paper to you today as the 
“Thiele syndrome,” I think if you refer to it con- 
stantly from now on, you probably will pick up 
some of the conditions that both Dr. Thiele and I 
have mentioned. 

When Dr. Ewell mentioned the “levator syn- 
drome” and gave Dr. Thiele credit for its observa- 
tion, he apparently had in mind also to designate 
definitely for the future a syndrome complex called 
“Thiele syndrome.” 




American Journal of Surgery 



THE LEFT^SIDED COLON* 


David A. Susnow, m.d. 
San Francisco, California 


T he term left-sided colon refers to that 
condition in which the entire colon in- 
cluding the cecum lies in the left side of 
the abdominal cavity. It results from a failure 
of the midgut to rotate in the second stage of 
rotation. This condition is of interest not only 
to the embryologist and anatomist but also to 
the surgeon as well because the latter may find 
himself unexpectedly faced with this unusual 
situation. Until recently the left-sided colon 
was recognized only post-mortem or during an 
abdominal operation. Today we appreciate the 
surgical importance of anomalies of intestinal 
rotation and no longer regard them as mere 
anatomic curiosities. During surgery the left- 
sided colon may be discovered as a totally 
unallied condition or as the cause of an acute 
abdominal emergency to which anomalies of 
intestinal rotation give rise. Of forty-eight 
cases collected by Dott^ thirty-five left-sided 
colons were discovered accidentally and thir- 
teen patients presented symptoms relevant to 
the anomaly. In thirty-three cases collected by 
Haymond and Dragstedt^ eighteen patients 
gave a history of gastric distress due to the 
anomaly and nine patients made no mention of 
abdominal discomfort. The left-sided colon was 
first observed radiologically in 1921 by Hurst.® 
Rubin'* has given an excellent description of its 
radiologic aspects. 

Embryology.^ In the earliest days of de- 
velopment the alimentary canal consists of a 
tube suspended in the midline of the abdominal 
cavity by a ventral and dorsal mesentery. By 
the end of the fifth week of intra-uterine life the 
alimentarj' canal is divided into the following 
three parts: the foregut which forms the 
stomach and duodenum down to the entrance 
of the bile duct, the midgut which extends from 
the ampulla of Vater to the junction of the 
middle with the left third of the transverse 
colon, and the hindgut which e.xtends from the 
left third of the transverse colon down to the 
anus. 

The e.xtremities of the midgut are firmly 
fixed by the upper duodenum above and the 


colic angle below. These two fixed points are 
close together and form the duodenocolic 
isthmus. The midgut forms a convex loop 
forward. Because of the rapid growth of the 
midgut and liver by the fifth week the midgut 
is forced into the root of the umbilical cord 
which forms a temporary developmental um- 
bilical hernia. (Fig. 1.) The midgut carries with 
it its arterj% the superior mesenteric, which 
terminates at the apex of the e.xtruded gut, the 
site of the vitelline duct. The superior mesen- 
teric artery runs from the aorta through the 
duodenocolic isthmus to the apex of the ex- 
truded gut sending off branches forward to the 
prearterial segment of the midgut loop and 
backward to the postarterial segment. 

ROTATION OF THE MIDGUT 

The first stage of rotation takes place be- 
tween the fifth to tenth week while the loop 
lies in the umbilical cord, during which time 
the ends of the midgut loop rotate through 90 
degrees in an anticlockwise direction (as one 
faces the fetus). 

The second stage of rotation commences at 
the beginning of the tenth week. (Fig. 2.) In 
this stage the midgut returns to the abdominal 
cavity and in so doing continues to rotate 
counterclockwise to a full 270 degrees. Frazer 
and Robbin® explain this return by the rela- 
tively decreased growth of the liver which 
makes room for the midgut in the abdomen. 
Due to the fact that it is not possible for the 
bulky hernial contents to return en masse 
through the narrow umbilical orifice, the con- 
tents are returned in a definite order. The 
cecum especially offers resistance to this 
passage. Because of the greater growth of the 
prearterial segment the proximal loops of small 
intestine are reduced first. While the prearterial 
loops are returning, the superior mesenteric 
arterj’- is firmly fixed to the umbilicus by its 
termination; and it is therefore stretched like a 
cord from beginning to end. The returning 
small intestine enters the abdomen to the right 
of the superior mesenteric artery. Because of 


* From the Proctology Clinic, Department of Surgery, Mt. Zion Hospital, San Francisco, Calif. 

Januarx', ig^o 


129 



130 


Susnow — ^Left-sided Colon 


the limited space the eoils first reduced are 
pushed to the left behind the taut artery by 
those following. They displace the dorsal 
mesentery of the hindgut, which occupies the 
midline, before them so that the descending 
colon comes to occupy the left flank and the 


mesenteric artery; (2) the transverse colon 
crosses in front of the superior mesenteric 
artery; (3) the descending colon has been 
pushed into the left flank; (4) the cecum is in 
the right loin under the liver and (5) the loops 
of small intestine extend from the left upper 




Figs, i to 3. Schematic drawing of normal development, rotation and attachment 
of the midgut. The midgut in each sketch is that part included between the dotted 
lines and represents that portion of the alimentary tract from duodenum to mid- 
transverse colon which is supplied by the superior mesenteric artery. (From “Ab- 
dominal Surgery of Infancy and Childhood,” Ladd and Gross.) Figure i, fifth week 
of fetal life; lateral view; the foregut, midgut and hindgut with their respective 
blood supplies are indicated. Most of the midgut is extruded into the base of the 
umbilical cord where it normally resides from about the fifth to the tenth week. 

Figure 2, tenth week of fetal life; anterior view; the intestine is elongating and the 
hindgut is displaced to the left side of the abdomen. The developing, intra- 
abdominal Intestines come to lie behind the superior mesenteric artery. A portion 
of the midgut still protrudes through the umbilical orifice into the base of the cord. 

Figure 3, eleventh week of fetal life; all of the alimentary tract is withdrawn into 
the abdomen. The cecum lies in the epigastrium beneath the stomach. A, aorta; 

C, cecum; CA, celiac axis; D, descending colon; F, foregut; H, hindgut; IMA, in- 
ferior mesenteric artery; SMA, superior mesenteric artery: UO, umbilical orifice 
and VD, vitelline duct. 

colic angle is pushed up to form the future 
splenic flexure. The last loop of ileum carries 
the superior mesenteric artery with it as it is 
reduced. The cecum and right half of the colon 
are reduced. The cecum lies free in the region 
of the umbilicus on a plane anterior to the small 
intestines and the superior mesenteric artery , 
from there it can pass in any direction. The 
colon tending to straighten ^ out carries the 
cecum upward and to the right and crosses 
the pedicle of the small intestine at the point of 
origin of the superior mesenteric artery frorn 
the aorta. (Fig. 3-) Subsequent growth and 
elongation pushes the cecum into the right loin 
under the liver. Thus when the second stage of 
rotation is completed, the following normal 
conditions are present: (i) The duodenum 
crosses behind the upper part of the superior 

American Journal 0/ Surgery 


to the right lower abdominal quadrants. 

(Fig. 4.) 

The third stage of rotation is concerned with 
the descent of the cecum and the fixation and 
fusion of various portions of the intestines to 
the posterior abdominal wall. The cecum 
descends from its position under the liver down 
into the right iliac fossa. (Fig. 5.) Theprimitive 
mesentery of the small gut becomes adherent 
to the posterior abdominal wall along a broad, 
oblique line from the left upper to the right 
lower quadrant. (Fig. 6.) The postarterial 
mesentery of the transverse colon persists as 
the transverse mesocolon. The mesentery of the 
cecum, ascending colon, hepatic flexure and 
hindgut becomes completely obliterated by 
fusion with the posterior parietal peritoneum 


Susnow — Left-sided Colon 


131 


except in the case of the pelvic colon where the 
mesentery persists as the future mesocolon. 

Because of the complex nature of the proc- 
esses involved in attaining its normal position 
it is readily understandable why abnormalities 
of location of the alimentary tract are almost 
entirely confined to the midgut. 


ileum occupy the right hypochondrium, lumbar 
and iliac regions; (4) the termination of the 
ileum may cross the midline to reach a left 
iliac cecum or it may terminate about the mid- 
line in a pelvic cecum; (5) the colon is confined 
to the left side of the abdomen; (6) the cecum 
is reversed and the ileum enters it from the 




Figs. 4 to 6. Late in eleventh week of fetal life; the colon is rotating so that the 
cecum lies in the right upper quadrant of the abdomen. Figure 5, rotation of the 
colon is complete and the cecum lies in a normal position. There is a common 
mesentery, the mesocolon of the ascending colon being continuous with the 
mesentery of the ileum. There is no posterior attachment of this common mesen- 
tery except at the origin of the superior mesenteric artery. Figure 6, final stage in 
attachment of the mesenteries; the stippled portions become fused and anchored 
to the posterior abdominal wall so that the ascending and descending parts of the 
colon are anchored and the mesentery of the jejunum and ileum have a posterior 
attachment from the origin of the superior mesenteric arterj’ obliquely downward 
to the cecum. (For further explanation see Figures i to 3.) 


NON-ROTATION OF MIDGUT 

The chief factor which determines a normal 
second stage of rotation is the sequence in which 
the midgut is returned from the umbilical cord 
to the abdominal cavity. It depends on the bulk 
of the cecum retaining it to the last in the 
hernial sac in the umbilicus while the more 
easily reducible small intestine enters first. 
However, in the presence of a lax umbilical 
ring the colon and cecum return first carrying 
with them the lower end of the ileum and the 
superior mesenteric artery. The small intestine 
immediate^ following will not tend to pass 
behind the artery, since the latter is not now 
held forward to the umbilicus, but rather to 
displace it and the large intestine to the left. 
The following features of non-rotation of the 
midgut according to Dott* are thereby pro- 
duced (Fig. 7): (i) The small intestine lies 
chiefly to the right of the midline; (2) the 
duodenurn passes down the right side of supe- 
rior mesenteric artery; (3) the jejunum and 

Januanr, iqjO 


right side; (7) the ascending colon passes up- 
ward from the cecum, usually a short distance 
to the left of the midline, to reach a position 
behind the greater curvature of the stomach; 
between this point and the normally placed 
splenic flexure a narrow U-shaped loop of 
transverse colon goes for a variable distance; 
(8) relation of the transverse colon to the 
greater omentum is normal and (9) the de- 
scending and pelvic colons take their usual 
course. 

In these abnormal sites the viscera undergo 
a great variety of secondary fixation by mesen- 
teric adhesions which tends to be imperfect. 

CONSEQUENCES OF LEFT-SIDED COLON 

_ Pathologic consequences arising from a left- 
sided colon are not due to its anomalous loca- 
tion but rather to the abnormal attachment 
and fi.xation and the inefficient fixation that so 
frequently accompanies the anomaly. Thus 



132 


Susnow — ^Left-sided Colon 


interference with motility and kinks and com- 
pression of the bowel may result. 

Secondary volvulus is the common patho- 
logic consequence of a left-sided colon. This is 
due to the fact that because the whole of the 
midgut shares a common mesentery, unless the 



Fig. 7. Schematic drawing of the left-sided colon; the 
colon occupies the left half or less of the abdominal 
cavity. The small intestine lies to the right side. The 
duodenum is elongated and its mesentery usually 
persists. The colon does not cross ventral to any part 
of the small intestine. The superior mesenteric artery 
lies dorsal to the duodenum sending branches to the 
small intestines from its right side and colic branches 
from its left side. 

ascending colon forms its secondary attach- 
ments, the small intestine, ascending colon and 
proximal half of the transverse colon may be 
freely suspended in their common mesentery 
by a narrow pedicle which is an ideal condition 
for volvulus. Extensive volvulus is character- 
istic in early life, usually shortly after birth. In 
later life volvolus of the ileocecal segment is 
typical. 

DIAGNOSIS 

Symptoms which accompany the left-sided 
colon are not due primarily to the misplacement 
but to the pathologic consequences which may 


result from inefficient or abnormal fixation of 
the various portions of the midgut. Symptoms 
may be vague in character or may be those of a 
typical partial or complete bowel obstruction 
depending upon the nature and e.xtent of the 
secondarj" involvement. Because a percentage 
will come under observation for symptoms 
which thej’^ have had since early childhood, the 
anomaly in these cases usually will be dis- 
covered by x-ray; but others will not be found 
until a bowel obstruction necessitates emer- 
gency surgery. Some will be discovered during 
the course of an examination or surgery for a 
totally unallied condition. 

The value of preoperative knowledge of the 
anomaly is evident. With this information 
the surgeon is in a better position to make a 
correct diagnosis and to plan and perform his 
operation accordingly. In those cases in which 
the surgeon finds himself confronted unex- 
pectedly with the anomolj' during surgery for 
a condition either directly related or totally 
unallied to the left-sided colon, it is manifest 
that the surgeon who is familiar with anomalies 
of intestinal rotation is at an advantage. (Table 
i.) Lack of knowledge predisposes to errors in 
procedure or injurious prolongation of the 
operation or its abandonment. 

CASE REPORTS 

Case i. Z. Y., a thirty-five year old white 
married woman was seen whose chief complaints 
were occasional bright red blood with bowel move- 
ments, constipation and abdominal distress. She 
was born with a cleft^ palate and an umbilical 
hernia. Plastic surgery was performed for the cleft 
palate when she was an infant and the umbilical 
hernia was repaired when she was thirty years of 
age. 

The patient had rectal bleeding with bowel 
movements off and on for several years associated 
with painful, protruding hemorrhoids. She had 
attacks of vague abdominal distress ever since she 
could remember. Abdominal pain at times was 
quite severe and constipation and distention 
developed. Attacks seemed to be brought on by 
dietary indiscretions and were relieved by enemas. 

Rectal examination showed moderately-sized, 
protruding internal hemorrhoids. Proctosigmoid- 
oscopy for a distance of 24 cm. from the anal verge 
was essentially negative as was the abdominal 
examination. There was no recurrence of umbilical 
hernia. 

Because of the complaint referrable to the ab- 
domen a gastrointestinal x-ray examination was 
done with the following results: 

A gastrointestinal x-ray was taken on April 17, 

American Journal of Surgery 







Susnow — Left-sided Colon 


133 


1 947. (Figs. 8, 9 and 10.) Fluoroscopy showed the 
chest was normal; the esophagus and stomach also 
were normal. The duodenal cap was spastic but 
otherwise normal. At six hours the stomach was 
empty and barium had reached the descending 
colon; the cecum lay deep in the pelvis to the left 
side and the remainder of the colon was to the left 


of the midline. Loops of small bowel containing 
barium were present in the pelvis and in the right 
abdomen. Opaque enema with air contrast, April 
19, 1947, confirmed the previous finding of the 
position of the colon. The conclusion was left-sided 
colon; no intrinsic organic lesion was present. 

This patient has been seen since from time to 


Table i 


Location of 
Incision 

Findings 

Anomalies to Be 
Considered 

Differential Diagnoses 

Right iliac region 

Large intestine cannot 
be found 

Non-rotation 

Duodenum passes down the right side of the root 
of the mesentery; duodenum not covered by 
colon or mesocolon 

Failure of descent of 
cecum 

Large intestine crosses duodenum; cecum found 
in subhepatic region or is folded back toward 
splenic flexure 

Upper abdomen 

Transverse colon not 
apparent 

1 

Non-rotation 

Duodenum not covered by colon or mesocolon; 
duodenum has free mesentery and passes down 
right side of root of mesentery; ascending colon 
passes up the left side of the vertebral column; 
no duodenojejunal flexure; upper loop of 
jejunum in right hypochondrium 

Reversed rotation 

Jejunum passes in front of mesenteric vessels 
from right to left; transverse colon behind origin 
of superior mesenteric artery; ascending colon 
in normal position; no duodenojejunal flexure; 
upper loop of jejunum in about midline in front 
of mesenteric root 

Left iliac region 

Large bowel is parallel 
to - the descending 
colon 

Non-rotation 

Abnormal colon, probably the ascending colon, 
passes up from a left-sided cecum on the left 
side of the vertebral column 



Fig. 8. Opaque enema showing short transverse colon and distal portion of ascending colon. Case i 

Fig. 9. Opaque enema after evacuation; cecum is deep in pelvis to left side- rnTon 1-,, - m - i r 

bowel in right abdomen and pelvis. Case i. ’ midline; loops of small 

Fig. 10. Opaque enema with air contrast dearly demonstrating position of entire colon. Case 1. 

January, 1950 
















134 


Susnow — Left-sided Colon 



Fig. 1 1. Opaque enema before cvacu- Fig. 12. Opaque enema after evacu- 
ation. Case II. ation. Case 11. 


time. She has been on a smooth diet and does not 
permit herself to become constipated. There have 
been no further severe attacks of abdominal pain 
although at times she has vague epigastric distress. 

Case ii.* M. K. L., a white male forty-seven 
years of age, complained of itching about the anus 
of twelve years’ duration. 

In 1929 he had pains in his stomach when it 
became empty. This pain was relieved by food and 
alkalis. No x-rays were taken at that time but he 
was treated for a peptic ulcer. There was a trace of 
sugar in the urine. 

The patient had itching about the anus for the 
past twelve years which was not relieved by low 
carbohydrate diet or various medications. His 
bowels had been normal. There was occasional anal 
discomfort with bowel movements and occasional 
epigastric distress which was relieved by alkalis. 

Examination showed simple fistula-in-ano at the 
posterior commissure with an associated anal 
fissure. Proctosigmoidoscopy and abdominal ex- 
amination were negative; urinalysis and a glucose 
tolerance test were normal. 

Because of the history of a possible peptic ulcer 
and the occasional epigastric distress a gastro- 
intestinal x-ray examination was done with the 
following results: The upper gastrointestinal tract 
was normal. The opaque enema (Figs, ii and 12) 
took a course obliquely upward to the left then 
looped downward before again turning upward to 
the splenic flexure. From this latter part the 
transverse colon filling was entirely to the left of 
the spine, the short ascending colon and cecum 
with the partially filled appendix being located in 
the pelvis. Scattered gas in the right abdomen 
represented loops of small bowel. The conclusion 
was left-sided colon. 

* Courtesy of Dr. E. A. French. 


COMMENT 

The two foregoing cases fall into that group 
of left-sided colons which is discovered acci- 
dentalljc To date neither patient has presented 
signs and symptoms requiring surgery for any 
of the complications incident to the anomaly. 
The patient in Case i may eventually require 
surgery because the occasional attacks which 
she has e.\’perienced are suggestive of partial 
obstruction due to volvulus. The patient in 
Case II will probably live out his normal span 
of years without any difficulties relevant to his 
left-sided colon. In anj’' event, armed with the 
knowledge of the existing anomalies the surgeon 
confronted with signs of obstruction in these 
cases will be in a better position to make a 
preoperative diagnosis and so can treat the 
condition adequately and satisfactorily. It 
should be noted that the patient in Case i had 
an umbilical hernia which required surgery. 
This fits in with the theory that a relaxed 
umbilical ring makes it possible for the cecum 
and colon to be reduced before the small intes- 
tine and to lay the groundwork for non-rotation 
.and a left-sided colon. 

SUMMARY 

The embryologic explanation of the left-sided 
colon has been presented. Its clinical signifi- 
cance and surgical importance has been out- 
lined. Two cases of left-sided colon have been 
presented in which no surgery relevant to the 
left-sided colon has been necessary to date. 

American Journal of Surgery 


Susnow — ^Left-sided Colon 


135 


REFERENCES 

1. Dott, N. M. Anomalies of intestinal rotation: their 

embryology and surgical aspects: with report of 
five cases. Brit. J. Surg., ii: 251, 1923. 

2. Haymond, H. E. and Dragstedt, L. R. Anomalies 

of intestinal rotation. Surg., Gynec. & Ohst,, $3: 
316-329, 1937. 

3. Hurst, P. F. and Johnston, T. B. Left-sided colon. 

Guy’s Hasp. Rep., 1:369, 1921. 

4. Rubin, E. L. Radiological aspects of intestinal rota- 

tion. LanceJ, 2: 1222, 1935. 

5. McGregor, A. L. A Synopsis of Surgical Anatomy, 

Rotation of the Gut. Chap. 12, Anatomy of Con- 
genital Errors. Baltimore, 1943. The Williams & 
Wilkins Co. 

6. Frazer, J. E. and Robbins, R. H. On the factors 

concerned in causing rotation of the intestines in 
man. J. Anat. & Physiol., 50: 75, 1915. 

DISCUSSION 

Arthur A. Gladstone (Burlington, Vt.): I am 
pleased that the condition known as left-sided colon 
has been brought to the attention of the society, 
because the surgeon who meets its complications 
may be embarrassed unless he is quite familiar with 
it. Doctor Susnow has succeeded in reviewing for 
us the stages in rotation in a very concise, clear 
manner and according to the most accepted 
theories. Embryology is something one reads, 
understands and soon forgets; at least that is the 
way with me. But one should remember and under- 
stand these steps because otherwise he cannot 
understand the pathologic findings he may en- 
counter associated with these abnormalities in 
rotation. 

In other words. Dr. Susnow did not present all 
this embryology just out of theoretic concern but 
because it has a very practical significance and 
application in the operative treatment and manage- 
ment of this problem. 

It is true that the condition is not too common. 
It has, however, been recognized for a long time; 
medieval anatomists described it. Besides the few 
cases of my own I am familiar with other such cases 
in our little state of Vermont, so I have a feeling 
that the condition is not as uncommon as the 
number of reported cases in the literature might 
lead us to believe. 

Since the problem, as Dr. Susnow explains, 
usually presents itself as a duodenal obstruction or 
volvulus, it is more apt to come to a general surgeon 
than to a proctologist; but if you happen to be in 
the hospital, in the next operating room or any- 
where around when some surgeon who is not too 
familiar with this condition encounters a complica- 
tion associated with a non- or malrotation, he will 
be very apt to call you in for advice. That is the 
"■ay I came to see the first case. Not all the patients 
are as fortunate as the ones in the cases Dr. Susnow 

January, ig^o 


reported who did not require surgery. 1 would like 
to tell you about one of my patients. 

An attending surgeon in our hospital was asked 
to see a baby five days old who began to vomit 
twenty-four hours after birth. Physical examina- 
tion revealed upper abdominal distention; a 
peristaltic wave could be seen across the upper 
abdomen and the referring doctor thought he 
could feel a mass in the pyloric region. The surgeon, 
however, could feel no mass; and because, the 
vomiting started so soon after birth and because 
bile was present in the vomitus, he did not accept 
the diagnosis of the referring doctor of pyloric 
hypertrophy. He thought the baby might have 
some anomaly, congenital band, obstruction to the 
duodenum from the superior mesentery or perhaps 
some stenosis. After the usual preparation, paying 
attention to hydration, blood changes, decompres- 
sion of dilated stomach etc., the baby was operated 
upon. A right rectus incision was made; on entering 
the abdomen the surgeon was surprised when he 
could see no small intestine. At this point I was 
called in to help in the interpretation of findings. 
The cecum was low in the midline and the ileum 
was seen to enter it from the right side. The 
ascending colon was to the left of the midline and, 
of course, no transverse colon was seen covering 
the duodenum. Everything from the duodeno- 
jejunal junction down seemed to be in a sac. We 
could trace the terminal ileum back a short distance 
from the cecum before it entered the sac. At first I 
thought we had a large retroperitoneal hernia but 
then reasoned that since the jejunal and ileal ends 
entered at different places and, further, since we 
found that the posterior parietal peritoneum was 
distinct from the posterior wall of the sac, we were 
not dealing with a hernia through the duodenol 
jejunal fossa. I later found similar cases described 
in the literature. It seems this sac is a ballooned-out 
pouch of mesentery of the lower position of the 
ileum. 

When this sac was entered, coils of small intestine 
seemed moderately dilated and slightly dusky in 
color. By placing a finger at the duodenojejunal 
junction, a sort of band was felt which proved to be 
a twist of the short mesentery that goes with this 
malrotation. Part of the small intestine had to be 
eviscerated before we could interpret what we had 
and untwist the volvulus. We also found a band of 
peritoneal reflexion that seemed to obstruct the 
duodenum and was probably as much responsible 
for the trouble as the partial twist of volvulus. 
Eighteen months have elapsed since the operation 
and the baby has done well except for two non- 
sustained bouts of vomiting. What we fear is a 
recurrence of the volvulus on that abnormally short 
mesenteric root. It is very possible that the bouts 
of vomiting were due to a recurrence of the incom- 
plete volvulus which corrected itself. 



136 


Susnow — Left-sided Colon 


One case I had which was discovered only with 
a routine roentgen exam was that of a man of 
forty. It is interesting because he presented upper 
abdominal symptoms for years similar to the case 
of Dr. Susnow’s. He was treated for a duodenal 
ulcer but none was ever discovered by x-ray 
e.xamination. It may be well to remember that it is 
the usual thing and not the e.\ception for patients’ 
symptoms to be referred to the upper abdomen in 
colonic obstruction. 

Df. Susnow mentioned the importance of keeping 
left-sidedjappendicitis in mind. A friend of mine had 
such a case in which diverticulitis and salpingitis 
were being considered in the differential diagnosis. 
Since both these conditions do not require imme- 
diate surgery, the danger of overlooking left-sided 
appendicitis is very possible. 

To repeat, we must be aware of the problem and 
its complication because operation is our only hope 
of cure and mortality will only mount with delay. 
In the case I cited we might have overlooked a 
volvulus of the entire mesentery if we were not 
aware of the pathologic condition involved and if 
we had not made a complete ex'ploration. 

M. H. Holehan (Memphis, Tenn.): I think 
Dr. Susnow has put much thought and study in his 
paper and the embryologic maneuvers that the gut 
goes through to get to the normal anatomic posi- 
tion. I will not try to enlarge upon this nor the 
anomalies that occur when this pattern is not 
followed. The two case reports leave nothing to be 
added. 

From a surgical standpoint it is well to know all 
of these conditions so that If an intra-abdominal 
pathologic condition arises and the physical facts 
and symptoms are somewhat peculiar, it may help 
you in making a more accurate diagnosis and cor- 
recting the condition. 

Personally I have not treated any left-sided 
colons and, therefore, I have taken the liberty of 
borrowing two from the John Gaston Hospital of 
Memphis. 

The first case is that of a twenty year old white 
female who had been in John Gaston Hospital on 


two previous occasions, one for a normal delivery 
and the other a pregnancy at time that was 
delivered by cesarean section due to a ruptured 
uterus. After leaving the hospital the patient was 
later seen in the outpatient clinic numerous times. 
Her chief complaints were indigestion, constipa- 
tion, intermittent cramping over pelvic region and 
severe aching pains usually following urination. 
She was again admitted to the hospital and a 
gastrointestinal series was done and the following 
noted. The duodenal loop appeared abnormal and 
did not present the usual configuration; it appeared 
to pass to the right directly with the jejunum with- 
out being attached to the ligament of Triste. 
Abnormality in the location of the cecum was also 
noted in the one-hour film. This was at a later date 
followed with a barium enema and the abnormality 
of the position of the right colon was clearly 
visualized. This patient had severe cystitis which 
was treated; the constipation was corrected and 
she was discharged. She has had no symptoms 
since. 

The second case is that of a white male twenty- 
eight years of age. He had an essentially negative 
history except occasional attacks of pain in the left 
lower quadrant which were gradually getting worse 
and were causing him to lose time from work. 
A barium enema was given and the right colon was 
found to be on the left side. Later an appendectomy 
was performed and patient made an uneventful 
recovery. 

David A. Susnow (closing): I have been asked 
what the incidence of the left-sided colon is. 
Frankly, I do not know; I have not been able to 
get any figures. However, in polling a number of 
surgeons and proctologists I was amazed to find 
how few men have seen even one case during many 
years of practice. In polling roentgenologists the 
average man may have seen only two or three cases 
in a lifetime. 

As a practical point should one encounter a left- 
sided colon during surgerj'- for volvulus, it is almost 
always necessary to eviscerate all of the mass onto 
the abdominal wall so that the point of volvulus 
can be demonstrated. 




American Journal of Surgery 


SACRAL BLOCK ANESTHESIA IN PROCTOLOGIC 

OPERATIONS* 


John S. Lundy, m.d. 
Rochester, A'linnesota 


M y experience with sacral block anes- 
thesia for proctologic operations ex- 
tends a little over the last twenty-five 
years. In this period I have had the opportunity 
to use sacral block for other types of operations. 
In addition to using this type of anesthesia for 
surgical operations I have used it for obstetric 
procedures and also for the diagnosis of pain 
paths in an attempt to block sacral nerves 
therapeutically. 

I have had an opportunity to compare a 
number of methods of anesthesia for proctologic 
operations and I know of no one method that 
offers so much satisfaction to the surgeon and 
the anesthesiologist, and usually to the patient, 
in terms of relaxation of the operative field and 
freedom from pain, as blocking the sacral 
nerves. In order to substantiate the basis of my 
assertion I shall summarize the annual reports 
of the Section on Anesthesiology of the Mayo 
Clinic since I was asked to head it early in 
1924. (Table i.) 

In the majority of a relatively large number 
of cases in which sacral block has been used a 
proctologic operation has been performed. In 
other words, the field in which this type of 
anesthesia has been used most frequently 
during this period has been proctologic sur- 
gery. From time to time I have been asked, 
“Why not use spinal anesthesia, because it is 
much easier to employ?” It is my opinion that 
spinal anesthesia is followed by postlumbar 
puncture headache often enough to make its 
use less desirable than sacral block. In a great 
many of the cases in which this type of anes- 
thesia has been used the block was produced by 
using a i per cent solution of procaine hydro- 
chloride with epinephrine in water or isotonic 
sodium chloride solution. In the second half 
of the scries of cases the block was obtained 
with a I per cent solution of metycaine which 
also contained epinephrine. In a small series 
of cases 250 units of penicillin per cc. were 
added to the i per cent solution of metycaine 
for the purpose of making available a solution 
* From the Section on Anesthesiol 


that might be needed in certain circumstances. 
This series was small but served to show that 
such a combination may be used in most cases 
without untoward results. In most cases in 
which patients are sensitive to penicillin skin 
manifestations may be seen at the site of the 


Table i 

ANESTHESIA AT THE MAVO CLINIC, 

1924 TO 1948 INCLUSIVE 

Cases 

Total number of cases in which an anesthetic 

was administered 555,246 

Regional block 125,702 

Spinal anesthesia 59,047 

Sacral and caudal block 22,895 

Intravenous anesthesia ( 1 935 to 1 948 inclusive) 94,774 
Pentothal sodium administered intravenously 

(1935 to 1948 inclusive) 92,620 


wheals in the skin. These manifestations may 
appear early in the postoperative period and 
may be expected to recur even months later 
if more penicillin should be taken by the 
patient. 

Dangers to be faced in the use of sacral block 
anesthesia are few but must be kept in mind. 
The solution may accidentally be injected into 
a vein and cause an untoward systemic effect. 
This may produce convulsions which can be 
controlled by the intravenous administration 
of small doses of pentothal sodium and by the 
administration of oxygen. If a small dose of the 
anesthetic agent is administered and if the 
anesthetic solution is injected slowly, the 
accidental injection of the solution into a vein 
is not likely to produce a severe reaction. If it is 
believed that the solution might have been 
injected into a vein, the patient should be 
watched carefully for evidence of an untoward 
sj'^stemic reaction. Perforation of the arachnoid 
and injection of the solution into the spinal 
fluid may produce anesthesia which extends 
high enough to anesthetize the spinal nerves. 
If a I per cent solution of procaine hydro- 
chloride is Inadvertently injected into the spinal 
fluid, fatal paralysis need not be anticipated if 
not more than 30 cc. of the solution is injected, 
y, Mayo Clinic, Rochester, Minn. 


January, ig^o 


137 



Lundy — Sacral Block Anesthesia 


138 

In most cases this is the maximal amount of a 
I per cent solution of procaine hydroehloride 
that should be injected into the caudal canal. 
The injection of a i per cent solution of mety- 
caine is a different matter. I know of one pa- 
tient who died after 30 cc. of this solution had 
been injected into the spinal fluid. The anes- 
thesiologist was not sufficiently experienced 
to know that he should have tested for spinal 
anesthesia at the first manifestation of distress, 
especially in regard to breathing, by the 
patient. If the anesthetic solution is acci- 
dentally injected into the spinal subarachnoid 
space, 100 cc. or more of the spinal fluid should 
be withdrawn and replaced with isotonic 
sodium chloride solution. 

The tip of the dural sac may be as low as the 
level of the second sacral foramen; therefore, 
the caudal needle should not be inserted higher 
than this level. One may traumatize the 
periosteal surface of the posterior part of the 
sacrum with the needle or needles employed; 
and if the point of the needle is passed re- 
peatedly through the skin and into the perios- 
teum of the sacrum, a sinus may form. I have 
observed one case in which such a sinus 
developed. If more than the average amount of 
solution is used and if the patient is somewhat 
sensitive to drugs, cardiovascular depression 
or even shock may occur. If the patient is an 
elderly or w'eak person, it is advisable to 
reduce the amount of solution from a third to a 
half. If time permits, it is sometimes possible 
to Introduce 25 cc. of solution into the caudal 
canal and allow thirty minutes for the develop- 
ment of anesthesia and relaxation. No further 
injection may be necessary. In some cases an 
intracaudal injection of 25 to 30 cc. of the 
anesthetic solution and injection of 10 cc. of 
the solution in each second sacral foramen will 
produce adequate anesthesia and relaxation in 
twenty minutes. For the most part, however, 
the. injection of 30 cc. of solution into the 
caudal canal, the injection of 10 cc. into 
the second sacral foramen on each side, the 
injection of 3 cc. into the third sacral foramen 
on each side and the injection of 2 cc. into the 
fourth sacral foramen on each side will produce 
good anesthesia in from ten to fifteen minutes. 
This technic causes a more or less complete 
distribution of the solution on all sides of the 
sacral nerves concerned which makes possible 
the quick, uniform and satisfactory anesthesia 
and relaxation that one wishes to produce. 
Nevertheless, the patient should be tested for 


anesthesia before the signal is given for the 
surgeon to start the operation. As time goes on 
the more one becomes experienced with the 
method the fewer are the failures that occur. 

If a physician is willing to learn the technic 
that will produce good results and if he will 
follow the technic carefull}^ it will not take 
him very long to be able to obtain uniformly 
good results. 

I should like to call your attention to the 
technic which I use for sacral block. There has 
been practically no change in this technic since 
1924 except that in the first three years the 
technic was worked out and finally was not at 
all like the one I first used. 

The patient is. placed in the Buie position 
which is the most satisfactory position for 
producing the bloek and for performing the 
proctologic operation. The skin is surgically 
prepared. The landmarks are palpated and 
drops of water are placed over the sacral 
hiatus and the foramina. Wheals are raised 
painlessly by putting the bevel of the needle 
against the skin and by forcing the anesthetic 
solution through the needle as it is engaged 
in the more superficial layers of the skin. 
Gradually the needle is forced deeper and 2 or 
3 cc. of the solution are then injected through 
the wheal and down to the periosteum. These 
wheals are raised after the eaudal needle has 
been inserted. One first raises a wheal in the 
skin over the sacral hiatus which may be 
palpated just above the coccyx. A small needle 
is inserted into the tip of the caudal canal and 
25 cc. of the solution injected. The needle is 
left in place. The caudal needle is inserted 
against the hiatus with the bevel up; then the 
needle is given a half turn and inserted not 
higher than the level of the second sacral 
foramen. Insertion of the needle should not 
produce blood or spinal fluid. 

In any event one must not inject any appre- 
ciable quantity of the solution into a vein. If 
one cannot find a satisfactory place for the 
needle even close to the tip of the caudal canal, 
it may be necessarj'^ to eliminate the caudal 
injection and make all injections from the 
foramina and also to deposit solution outside 
of the sacral hiatus. After the caudal injection 
has been made, needles should be inserted into 
the second, third and fourth sacral foramina 
on each side. Wheals are raised as described 
and infiltration is made as the needle is inserted 
from skin to bone. Then one should search for 
the foramen by inserting the needle against the 

American Journal of Surgery 


Lundy — Sacral Block Anesthesia 


139 


sacrum at several points near the first spot 
touched. At this point the wheal is moved in a 
circular position each time the needle is 
almost withdrawn except from skin and re- 
inserted. The needle is inserted as around the 
dial of a clock and six thrusts are made. 
The first one is in the center of the circle 
and the other five around it. If one cannot 
find the foramen in six thrusts, he probably 
will not find it in sixty. He should try another 
foramen; and if he does not find that one, he 
should try to find the next one. He should start 
with the fourth sacral foramen and end with 
the second because in caudal block the anes- 
thesia starts at the bottom and extends up- 
ward. Insertion of the needle into the fourth 
sacral foramen is less painful than into the third 
and insertion into the second foramen is less 
painful than into the third. 

When the needle is inserted into the foramen 
which is bottomless, one must be very certain 
that the point of the needle enters the foramen 
for as short a distance as possible. If the needle 
is inserted beyond the thickness of the sacrum, 
all the solution will go into the pelvis and none 
will enter the foramen. In the case of small, 
sensitive or weak patients the total amount of 
solution used seldom exceeds 60 cc. and may be 
as small as 35 to 40 cc. 

Only once in my e.xperience at the clinic did 
we perform a proctologic operation on a patient 
under nitrous oxide-oxygen and ether in the 
lithotomy position. This patient was a doctor’s 
wife whom I had anesthetized three times for 
delivery. I had tested her for sensitivity to 


procaine and metycaine. She did not tolerate 
either one in skin wheals but I found that she 
reaeted well to inhalation anesthesia. She was 
the one exception that spoiled what would have 
been otherwise considered a sort of record. 

In a case of pilonidal disease in which con- 
siderable infection precludes the use of sacral 
block spinal anesthesia has been used with 
complete satisfaction except for an occasional 
instance of headache. 

In a very few cases in which a minor opera- 
tion was to be done such as incision of an 
abscess or removal of a painful pack pentothal 
anesthesia has been used. In a very few cases 
in which general anesthesia of not more than 
fifteen minutes duration was needed pentothal 
sodium has been used. 

The use of curare as an aid to pentothal 
sodium. may possibly lead to an increased use 
of the combination and it may be that sacral 
block will go the way of spinal anesthesia if the 
possibility of using curare plus equal parts of 
nitrous oxide and oxygen continues to be used 
more generally than it has been. 

Perhaps a method will be worked out in time 
that can equal the record established by sacral 
block. This will take some time, however. 
Although I do not wish to predict that nothing 
better can be found for proctologic surgery 
than blocking of the sacral nerves, I hope to be 
pardoned if I look upon the results obtained 
Avith this method with some degree of satis- 
faction. If a new and better method of anes- 
thesia is developed for proctologic operations, 
I shall be very eager to live to see it. 


€ 12 ^ 


Januaryr, jg^o 



PENTOTHAL SODIUM IN ANORECTAL SURGERY 

ANALYSIS OF 1,500 CASES 

Ralph E. Grigler, m,d. 

Fort Smith, Arkansas 


T he author wishes in this article to 
present his observations as a surgeon of 
the use of pentothal sodium anesthesia 
given by a trained nurse anesthetist in 2,531 
consecutive cases anesthetized for minor ano- 
rectal operations. Of these cases 1,500 were for 
operative procedures and 1,031 for the post- 
operative removal of rectal packs. 

Pentothal sodium was first introduced as a 
new intravenous anesthetic in June, 1934, by 
Lundy. After the introduction of this drug it 
was believed that its field had certain limita- 
tions, that it should be used only in minor 
operations not requiring over fifteen to twenty 
minutes and that it was not adaptable for use 
in rectal surgery. 

Erroneous conclusions were drawn by several 
who read the first few articles published and, as 
a result, several fatalities were reported be- 
cause of the improper administration of 
pentothal sodium. During the past fifteen 
years, however, much has been learned about 
this new drug and it has been successfully used 
in all branches of surgery and in operations 
requiring from a few minutes to several hours 
of anesthesia. 

One outstanding feature of the literature on 
pentothal during 1943 was the frequent men- 
tion of its use in military surgery in both 
combat and base areas. These reports indicate 
that pentothal sodium has been ptensively 
used in military medicine and that it has been 
applied, either alone or in conjunction with 
other anesthetic agents, for practically all types 
of operative procedures. The frequency of the 
use of pentothal sodium anesthesia has varied 
in different military organizations and it would 
appear that the agent is relied upon more often 
as the operating team approaches or enters the 
combat area. Some military anesthetists have 
reported that pentothal sodium was used in 
95 per cent of their cases. A number of factors 
have contributed to this extensive use of 
pentothal in niilitar3^ surgery, namely, ready 
availability, ease of transport, simplified equip- 
ment, rapidity of induction and recovery, ease 


of administration and control, and the low 
incidence of postoperative complications. It 
was also noted that pentothal was partieularly 
well tolerated by the type of patients requiring 
war surgery. 

Pentothal sodium is a derivative of barbituric 
acid. It differs from nembutal by the replace- 
ment of I atom of o.xygen by a sulfur atom on 
the urea side of the molecule. It is the trade 
name for sodium ethyl (i methylbutyl), thio- 
barbituric acid. It is a lemon-colored powder 
with a bitter taste and an odor similar to 
acetylene gas. It dissolves readily in distilled 
water and when dissolved should form a clear 
solution with a yellow tinge. A cloudy solution 
should not be utilized. Only fresh solutions 
prepared within two hours should be given as 
deterioration occurs rapidly. Pentothal sodium 
is a respiratory depressant with relativel5’^ little 
untoward action on the heart. In animal 
experimentation an overdose of pentothal 
affects the respiratory center before the cardio- 
vascular center. Respiratory failure results 
although cardiac action may continue for 
fifteen to twenty minutes after the cessation 
of breathing. For this reason when respiratory 
failure does occur d\iring pentothal anesthesia, 
artificial respiration, - using oxygen with very 
light pressure, can be used eEfectivelJ^ This 
depression is negligible when pentothal is used 
in therapeutic amounts. If the drug is Injected 
too rapidl3% respirations become shallow and 
cj'-anosis may occur although the rate and 
rhythm of the heart are not influenced and any 
pre-existing irregularities remain unchanged. 
The hemoglobin, red blood count, white blood 
count, differential and urinaE^sis before, during 
and after anesthesia with pentothal show no 
noticeable change. The same is true for the 
blood chemistry, including the blood sugar, 
non-protein nitrogen, uric acid, creatinine, 
coagulation and bleeding time. 

It must be emphasized, however, that pento- 
thal sodium is like all other anesthetics in one 
respect; it is dangerous and can result in a 
mortality unless properly administered. For 

American Journal oj Surgery 



Crigler — Pentothal Sodium 141 


this reason it should never be used in the 
physician’s office or in the patient’s home; it is 
a hospital procedure. 

As stated by several authors it is an ideal 
anesthetic because the patient has to recover 
only from the operation and not from the 
after-effects of the anesthetic such as follow 
other general anesthetic agents. It is the con- 
sensus of most writers that pentothal decreases 
mortality, especially in the aged patients and 
those who are poor operative risks. 

We have been somewhat hesitant to use 
pentothal in children under ten to twelve years 
of age. As a rule, in our hands these youngsters 
do not tolerate a barbiturate intravenously 
very well because of their susceptibility to 
respiratory depression and the difficulty of 
maintaining a patent airway. Moreover, veni- 
puncture is more difficult because of their fear 
of the needle and their small veins. In this 
series of 1,500 cases there were only five 
patients given pentothal sodium under the age 
of twelve years. 

PREOPERATIVE MEDICATION 

In this series the patients were admitted to 
the hospital the day before surgery. A complete 
blood count, urinalysis, routine history and 
physical examination were made. Preopera- 
tively, the patients were given a liquid diet 
for their evening meal, a cleansing enema, 
sodium amytal, 3 gr. and seconal, gr. at 
bedtime the evening preceding surgery. Vari- 
ations in this routine were used with children 
and aged patients. Thirty minutes prior to 
surgery, dilaudid, gr. Ii2, and atropine, gr. 
KoOj were given hypodermically unless age or 
condition warranted a different dosage. 

ADMINISTRATION OF PENTOTHAL 

Different concentrations of pentothal sodium 
solutions ranging from .5 per cent to 5 per cent 
have been given and advantages have been 
claimed for the different concentrations. The 
consensus leans toward a per cent solution 
as being the ideal concentration. In this series 
only a 5 per cent solution was used. The patient 
is placed in the lateral Sims position and given 
I cc. of the drug over a period of four to six 
seconds, after which he was encouraged to talk 
or count. A second cc. was then given during a 
period of five to six seconds. This intermittent 
type of injection was repeated until the patient 
ceased to talk or count. Light anesthesia was 
usually established vithin thirty to forty 

Januan’-, 1950 


seconds. At this time the patient’s tongue w'as 
pulled forward and an airwaj'' was inserted to 
assure clear passage. Before the anesthetic was 
started the gas-oxygen machine was made 
available and metrazol, picrotoxin, curare and 
coramine w'ere in reach of the anesthetist. After 
inserting the airway the administration of 
pentothal was discontinued for thirty seconds 
and thereafter i to 2 cc. were injected at 
intervals as indicated. Indications for further 
injection were noted by slight movement of the 
extremities, reflex movements due to painful 
stimuli or an increase in depth of respiration. 
The best guide to the depth of anesthesia is 
respiration. During light anesthesia the re- 
spiratory excursions are full and in deep 
anesthesia the excursions became shallow. At 
the end of ninety seconds the operative field 
is prepared, draped and the sensibility of the 
patient is tested by gentle digital rectal 
examination. If there is any reflex spasm, time 
is allowed for the administration of another cc. 
or two of pentothal. By using a 5 per cent 
solution of pentothal sodium for anesthesia 
complete surgical anesthesia is obtained much 
more quickly than when a 2)4 Per cent solution 
is used. In all these cases, unless contraindicated 
by infection or’ abscess formation, 5 cc. of an 
oil anesthetic (zylcaine) were injected in and 
about the perianal region before any surgery 
was started. This oil anesthesia is used rou- 
tinely not to reinforce the sodium pentothal 
but because of Its prolonged effect, lasting some 
ten days to two weeks, which minimizes post- 
operative pain and discomfort. Oxygen was 
never used routinely. The gas-oxygen machine 
was available, however, and was used in less 
than 2 per cent of these cases when the respira- 
tions were shallow or a laryngospasm or 
cyanosis occurred. The amount of pentothal 
given varied from .13 to 2 Gm. 

The average duration of anesthesia from the 
time the anesthetic was started until the patient 
awoke in the room was fifty-one minutes. 
The average time consumed for the operation 
w'as twenty minutes. 

As mentioned before this entire series 
concerns only minor anorectal surgery. Many 
of the individual patients had two or more 
separate pathologic processes. 

In spite of all that has been written about 
getting away from rectal packs and using 
oxycel or gelfoam we still use the old-fashioned 
rectal pack of cotton and vaseline gauze 
wrapped around a rubber catheter. We believe 



142 


Crigler — Pentothal Sodium 


there is less difficulty in establishing adequate 
postoperative dilatation. In the past the re- 
moval of these packs has caused the patient 
considerable pain, distress and spasm of the 
sphincter muscle which lasted for a number of 
hours. Since December, 1946, we have been 

Tablu I 

DIAGNOSIS 

No. of 

® Cases 


Cryptilis 1,341 

Fistula-in-ano 21 1 

Internal hemorrhoids Q25 

E.xtcrnal licmorrhoids 141 

Prolapsed hemorrhoids 56 

Fissure-in-ano 201 

Rectal abscess 49 

Pilonidal cyst 38 

Polyps 22 

Anal stricture 25 

Pruritis ani 115 

Papillitis 120 


Table ii 

AGE INCIDENCE 


Years 

Males 

Females 

o-io 

2 

3 

10-20 

6 

•7 

20-30 

84 

132 

30-40 

170 

278 

40-50 

176 

266 

50-60 

104 

128 

60-70 

57 

52 

70-80 

10 

'4 

80-90 

0 

I 

Total 

600 

891 


removing these rectal packs in the patient’s 
room under pentothal anesthesia. The patient 
is in a lateral Sims position and 3 to 6 cc. of a 
5 per cent solution of pentothal sodium are 
given the patient intravenously. The pack is 
removed and continuous hot, wet, saline packs 
are applied to the rectum. Often these patients 
will wake up and start counting where thej"^ 
left off. Sometimes the nurse has trouble con- 
vincing them that they have been asleep and 
that the pack has been removed. Since this 
procedure was started, 1,031 patients have 
been treated without a single complication. 
None of these patients has slept over ten 
minutes and usually he is awake in three to 
five minutes. As a rule, the following morning 
the patient receives a saline enema after which 
he is placed in a hot sitz bath. He is up and 


about from then on and either goes home that 
afternoon or the following morning. At the 
time this paper was written the packs were 
removed on the second postoperative day. 
Since March i, 1949, xve have been using a 
sheet of oxycel gauze wrapped around the 

Table hi 

PATIENTS WITH PHYSICAL I.MPAIRMENTS 

No. of 


Impairments Cases 

Red blood count under 4,000,000 482 

Hemoglobin under 80 per cent 414 

Albuminuria 245 

Active tuberculosis 13 


Blood pressure with systolic pressure over 200. . 19 

vaseline gauze. This forms a jelly-like dark 
substance. The pack all but comes out of its 
own accord the following morning at the end 
of twenty-four hours. This, of course, has now 
eliminated the pentothal anesthesia for the 
removal of packs. 

As shown by Table ii the ages of these 
patients ranged from seven years to eighty-six 
years of age; 609 were males and 891 were 
females. 

Although several authors insist there are no 
contraindications to the use of pentothal 
sodium if properly administered, we have made 
note of a number of cases that could be con- 
sidered to have had phj^sical impairments. 

The only complications we have encountered, 
and none of them serious, were: 

Table iv 

COMPLICATIONS 

Anesthesi.T undul3' prolonged:* 


1 H to 2 hr 88 

2 to 3 hr 43 

3 to 4 hr 8 

Laryngospasm 22 

Venous thrombosis 9 


* The duration of anesthesia includes from the time 
the anesthetic was started in the operating room until 
the patient awoke in the room. 

We have found during the past twelve to 
fourteen months that the undue prolongation 
of anesthesia can be prevented by the adminis- 
tration of I to 3 cc. of metrazol given intra- 
venously when the patient leaves the operating 
room. The amount given is determined by the 
depth of anesthesia. 

With reference to thrombosis of the vein used 
in the cubital fossa none of these was serious; 
each one cleared up within ten to twenty-one 
days. 

Some surgeons may consider the incidence 
of postoperative complications as unusually 

American Journal of Surgery 



Crigler — Pentothal Sodium 


143 


high. All ihe complications reported, however, 
were very mild. An attempt was made to keep 
an accurate record of the slightest possible 
complication in order that pentothal sodium 
might be correcth'^ evaluated from the stand- 
point of safety for anorectal operations. It is 
our belief that the complications which have 
occurred have been of sufficient mildness to 
justify our continuation of the use of this agent 
and are no worse or more numerous than those 
which we have seen following the use of other 
spinal or local anesthetic agents. In our experi- 
ence we have been satisfied with the use of 
pentothal sodium and hope to be able to 
continue it. 

CONCLUSIONS 

Pentothal sodium has been demonstrated to 
be a safe anesthetic, if properly administered, 
in anorectal surgerj^ the use of pentothal 
sodium involves a minimum loss of time in the 
operating room for the production of surgical 
anesthesia and it is pleasing to the patient as 
well as the surgeon inasmuch as postoperative 
nausea and vomiting are practically eliminated. 

REFERENCES 

1. Adams, R. C. Pentothal sodium intravenous anes- 

thesia in peace and war. J. A. M. A., 126: 282, 

1944 - 

2. Battaglia, D. and Winne, B. A. Pentothal sodium 

anesthesia in major surgery. Neiv York State J. 

Med., 44: 1120-1123, 1944. 

3. Carraway, C. N. and Carraway, B. M. Adminis- 

tration of pentothal sodium oxygen anesthesia. 

J. M. A. Alabama, 12; 325, 1943. 

4. Edwards, S. and Hand, L. V. Intravenous anes- 

thesia. 5 . Clin. North America, 22: 925-932, 1942. 

5. Fisher, K. Pentothal anesthesia as used in a small 

hospital. Kentucky M. J., 39: 145, 1941. 

6. Hess, E. and Merski, A. T. Some observations in 


the use of pentothal sodium. Urol. & Cutan. Rev., 
46: 709-713. 1942. 

7. Long, C. H. and Ochsner, A. Intravenous pento- 

thal sodium anesthesia. Surger}', 1 1 : 474, 1942. 

8. Lundy, J. S. Intravenous and regional anesthesia. 

Ann. Surg., no: 878-885, 1939. 

9. Lundy, J. S. et al. Annual report for 1942 of section 

on anesthesia. Proc. Staff Meet., Mayo Clin., 18: 
129, 1943. 

10. Porter, A. R. Intravenous anesthesia. A'lempbis 

M. J., 15: 3, 1940. 

11. Rose, A. T. Sodiurh. pentothal. Anesthesiology, 4: 

534, 1943. 

12. ScHEiFLEY, C. H. Pentothal sodium. Anesthesiology, 

7: 263, 1946. 

13. Searles, P. \V. and Lenaham, R. M. Intravenous 

anesthesia. Neiv York State J. Med., 48: 1699, 
1948. 

14. Tucker, A. C. Intravenous anesthesia with pento- 

thal sodium in general surgery. Northivest Med., 
38: 246, 1939. 

15. Carraway, C. N. and Carraway, B. M. Pento- 

thal-oxygen anesthesia. J. M. A. Alabama, 12: 
325, 1943. 

16. Seplo, j. a. The medical department of a battleship 

in action. U. S. Nav. M. Bull., 41: 1213, 1943. 

17. Rose, A. T. Sodium pentothal; actual experience 

in the combat zone. Anestbe.siology, 4: 534, 1943. 

18. Carr, C. R. and LaMathe, D. E. Sodium pento- 

thal anesthesia in intra-oral surgery at sea. 
U. S. Nav. M. Bull., 41: 1374, 1943. 

19. Moorhead, J. D. Trends in war surgery; anes- 

thesia. S. Clin. North America, 23: 313, 1943. 

20. PicKRELL, K. L. and Richards, R. K. Pentothal- 

metrazol antagonism. Ann. Surg., 121 : 495, 1945. 

21. Gould, R. B. Intravenous Anesthesia in War 

Surgery. Anestb. & Analg., 25: 115, 1946. 

22. McAllister, F. F. The effect of pentothal sodium 

on mean arterial blood pressure in the presence 
of high spinal cord paralysis. Ann. Surg., 124: 
328, 1946. 

23. Kohn, R. and Lederer, L. Pentothal studies with 

special reference to the electrocardiogram. J. 
Lab. cy Clin. Med., 23: 717-728, 1938. 

24. Carraway, B. M. Penthal sodium with nasal 

oxygen. Anestb. ef Analg., 18: 259-269, 1939. 

25. Tovell, R. M. and Garofalo, M. An evaluation 

of intravenous anesthesia. New York State J. 
Med., 39: 21, 1939. 


& 


January, ig^o 



SPINAL ANESTHESIA IN PROCTOLOGY 


A. Gerson Carmel, m.d. 
Cincinnati, Ohio 


T he ideal anesthetic in proctologic proce- 
dures should: (i) eliminate pain during 
the operation, (2) produce local relaxa- 
tion so as to permit optimum exposure without 
undue trauma, (3) cause no undesirable con- 
stitutional or local effects, (4) produce cerebral 
sedation sufficient to allay the apprehension 
of the patient and cause him to remain quiet 
and cooperative during the operation, (5) have 
a wide range of applicability even in the 
presence of other diseases, (6) result in speedj' 
recovery and (7) employ the smallest quantity 
of drugs that will consistently result in satis- 
factory anesthesia. 

A close approach to this ideal is afforded by 
the use of a small quantity of procaine com- 
bined with epinephrine injected subarach- 
noidalljr. Preliminar}' cerebral sedation is 
obtained by the oral administration of a soluble 
barbiturate and the hypodermic injection of 
morphine sulfate and scopolamine. 

The soluble barbiturate is usually pento- 
barbital sodium (nembutal) which is given as a 
gr. capsule the night before operation and 
repeated one hour preoperatively. Three grains 
have been employed but this dose may be dis- 
advantageous for routine use. One and a half 
grains produces desirable cooperation while 
twice this quantity frequently results in un- 
cooperative somnolence during which the 
patient involuntarily and reflexlj’’ moves about 
during the insertion of the spinal needle and in 
response to pressure stimuli. Seconal has 
occasionally been used in place of nembutal 
and is satisfactory. Morphine sulfate and 
scopolamine are administered a half hour 
before the scheduled time of operation. The 
average dose of morphine sulfate is gr. but 
in a large individual it is increased to g''- ^^d 
in a small or elderly person it is decreased to 
^'8 or 3.^2 gr- The dose of scopolamine is 
usually Hoo or gr- but it is reduced to 

Moo gr- when the patient is small or elderly. 
Frequently morphine and scopolamine have 
been omitted. After the spinal anesthetic has 
been administered and the patient placed in 
the operative position, he frequently dozes or 


sleeps soundly throughout the remaining 
procedure. 

This paper is based on an experience* of 
fifteen years and the technic of anesthesia 
described has been satisfactorily employed in 
over 1,200 patients. During the period covered 
by this report comparisons were provided bj'^ 
more than 3,000 related cases who received 
anesthesias other than the type described 
herein which included: general, intravenous, 
caudal, transsacral, spinal and local infiltration. 
Those patients in this group who received spinal 
anesthesias were given the classic doses of 
procaine or pontocaine. Later, as a result of our 
success with small doses of procaine epinephrine 
we were prompted to reduce gradually the 
amount of pontocaine used so that now it is 
insisted that the anesthetist administer no 
more than 3 or 4 mg. 

Earlj"^ in this work small doses of procaine 
hydrochloride dissolved in distilled water were 
employed which had been prepared and steril- 
ized in the hospital. The anesthesia was of 
short and variable duration. Furthermore, it 
was feared that the risk of infection was 
greater than that with commercially prepared 
ampules. The use of such preparations was soon 
discontinued. 

Among the unsatisfactory preparations was 
a commercial ampule of 2 per cent procaine 
without epinephrine. It produced anesthesia 
more uniformly and of greater duration than 
the solutions prepared in the hospital. How- 
ever, the effectiveness of small doses was less 
constant than desired. The results were some- 
what improved with the use of procaine 
crystals in doses of 20 to 25 mg. dissolved in 
the spinal fluid of the patient. Also not satis- 
factory was 20 mg. of procaine in solution with 
1 : 50,000 epinephrine because the duration of 
anesthesia was not sufficient. 

Fourteen milligrams of procaine in a 2 per 
cent solution with 1:20,000 epinephrine has 
occasionally produced anesthesia that lasted 
forty-five minutes but frequently the desired 
effect is much less. Hence, this dose is reserved 

* This work was initiated at Longview Hospital. 

American Journal of Surgery 


144 


145 


Carmel — Spinal Anesthesia 


for procedures that will require only ten to 
fifteen minutes after which the patient recovers 
the effective use of his lower extremities. 

Twenty milligrams of procaine in a com- 
mercial ampule of a 2 per cent solution with 
1 : 20,000 epinephrine has been eminently satis- 
factory. The preparation employed is heavier 
than spinal fluid. Each cubic centimeter con- 
tains 20 mg. of procaine hydrochloride, 0.05 mg. 
of synthetic epinephrine,* as bitartrate, 2 mg. 
of sodium chloride, 4 mg. of potassium sulfate 
and 1.5 mg. of sodium bisulfite. One cubic 
centimeter of this solution, when meticulously 
administered, produces effective anesthesia of 
the anorectal area lasting from one to one and 
a half hours. The dose is the same irrespective 
of the size or sex of the patient. The results 
have been just as satisfactory in individuals 
weighing 250 pounds as in those weighing as 
little as 90 pounds. 

TECHNIC 

The sitting position is preferred for the 
administration of the anesthetic. However, if 
the patient’s proctologic condition is so painful 
as to prevent him from sitting he may lie on one 
side. The interspace selected for the site of 
injection is on the level with or just below the 
crest of the ilium; if obstacles are encountered 
at this point, an interspace lower or one higher 
is chosen although this is rarelj'' necessary. A 
20 or 22 gauge 3-inch needle is employed with 
the stylet in place and withdrawn just behind 
the point of the needle. Usually no procaine is 
injected subcutaneously because a precise 
injection in an adequately sedated patient 
seems to entail no more discomfort than the 
preliminary injection subcutaneously of an 
anesthetic solution. But in exceptional cases 
in which it is anticipated that difficulty will be 
encountered the skin and subcutaneous tissues 
are anesthetized by local infiltration before the 
lumbar puncture needle is inserted. After the 
subarachnoid space has been entered, ten to 
fifteen drops of spinal fluid are allowed to 
escape. It must be emphasized that a free flow 
of spinal fluid is imperative here as it is in the 
administration of all spinal anesthetics. Ne.\t 
a 2 cc. syringe containing i cc. of the prepara- 
tion is attached to the needle. The piston of the 
syringe is withdrawn slightly so as to be assured 
of a free flow of spinal fluid and the solution 

* There is 0.06 mg. of epinephrine in i m. of i : 1,000 
solution of epin ephrinc. 

J amiary, ig^o 


is injected in eight to fifteen seconds. The piston 
is again withdrawn just sufficiently to be cer- 
tain that the needle has not been displaced 
during the procedure. The needle with the 
syringe attached is held in place for another 
forty-five to sixti”- seconds assuring no loss of 
the drug during this time. The patient is placed 
flat on his back for two to four minutes. After 
this the trunk is depressed for about 3 degrees 
for one minute. The changes in position 
promote an adequate distribution to all the 
nerve roots supplying the anal canal and lower 
rectum. 

The patient is next placed in the position for 
operation which is customarily either the left 
lateral or the Buie prone position with the 
trunk and thighs slightly depressed. The latter 
position is achieved by the use of a special 
table or by placing a pillow under the lower 
abdomen. By the time the operative area has 
been cleansed and painted with antiseptic 
solution, anesthesia and local relaxation are 
complete. 

Two deviations from the routine require 
emphasis. If the patient has been lying on his 
side during the insertion of the needle, imme- 
diately after the drug has been injected the 
needle is withdrawn and the patient is placed 
on his back as previously described thus 
promoting bilateral spread of the anesthesia. 
If the patient lies on his side during the opera- 
tion, it is wise to operate on the upper side first 
because the anesthesia is of shorter duration 
on this side. 

The blood pressure usually remains un- 
changed but occasionally a rise or a drop of 
10 mm. may occur. This may be attributed to 
the anesthetic but it may be due to the change 
in position of the patient or to his inactiveness. 
The method has been employed in hyper- 
tensive and hypotensive cases without the 
production of ill effects. In this series the 
highest sj’^stolic blood pressure w'as 260 and 
the lowest 95 mm. of mercury. The pulse and 
respiration remain unchanged. It has not been 
necessary to administer a stimulant to any 
patient in this series. The mental state of the 
patient is tranquil; many sleep during the 
operative procedure. The duration of the anes- 
thesia is one hour or longer, frequently as long 
as one and a half hours. Since the customary 
proctologic procedures rarely last more than 
one-half hour to one hour, the surgeon can with 
confidence employ this small dose in the manner 
described. The use of the lower extremities is 



146 


Carmel — Spinal Anesthesia 


usually regained within one hour after the anes- 
thetie reagent has been injected. 

Special postanesthetic care is not required. 
The patient may move around in bed or get up 
to void and may receive fluids and nourishment 
orally whenever desired on the day of operation 
provided that he has not been too heavily 
sedated preoperatively. Certain urgent proce- 
dures need not be delayed until a hospital 
bed becomes available because they may be 
performed in the hospital operating room and 
the patient transported to his home imme- 
diately without fear of postancsthetic com- 
plications. This is an advantage over anesthetics 
which require several hours for recovery. 

An additional advantage of the preparation 
employed is that the material is contained in 
one ampule thus eliminating the need for 
mixing with other drugs as glucose or with the 
spinal fluid as is required when the anesthetic 
drug is in crystalline form. Furthermore, in 
common with other spinal anesthetics the 
supplemental use of measures to obtain relaxa- 
tion such as curare are unnecessary. 

COMPLICATIONS 

Headaches have been the only complication 
observed occurring in 6 per cent of the patients. 
Their duration and severity with therapy has 
not been marked and most of them lasted a 
day, none more than three days. Aspirin com- 
pound, magnesium sulfate, caffeine sodium 
benzoate and nicamin administered intra- 
venously have been successful in combating 
the headaches. Since the value of nicamin in 
this regard has been pointed out, it has been 
used most frequently. One to three doses of 
50 to 100 mg. administered intravenously has 
afforded relief. Niacinamide orally either alone 
or in a mixed vitamin preparation has been 
recently employed with gratifying results. The 
dose has been 1 00 to 200 mg. three times daily. 

Postoperative catheterization has been vir- 
tually eliminated with this form of anesthesia. 

INDICATIONS 

As described spinal anesthesia appears to be 
a desirable routine in surgery of the anorectal 
area. The negligible changes in blood pressure, 
pulse and respiration suggest that it is more 
desirable than inhalants or intravenous anes- 
thesia in the poor risk patient. The absence of 
apprehension and physical strain that is often 
present during even a skillful administration of 
a local anesthetic also suggests that it may be 


actually safer than local infiltration in such a 
patient. Its ease of administration and uniform 
success in producing anesthesia may make it 
preferable to caudal or transsacral block or it 
may be a convenient substitute when the 
latter methods have failed or are impossible 
because of anatomic abnormalities. 

contraindications 

There are few contraindications to spinal 
anesthesia administered in this manner. They 
include infection in the area through which the 
lumbar puncture needle must pass, determined 
opposition on the part of the patient against 
this form of anesthesia, pre-existing chronic 
backache, anal incontinence or other conditions 
which the patient later may attribute to the 
subarachnoid injection and anatomic abnor- 
malities which make it impossible to insert a 
needle into the subarachnoid space. These 
contraindications are rare. 

SUMMARY 

1. A technic is described of securing spinal 
anesthesia with 20 mg. of procaine in a hyper- 
barit solution containing i : 20,000 epinephrine. 

2. The method is uniformly safe. Blood 
pressure changes are absent or minimal. . 
Changes in pulse and respirations are absent. 
Little or no undesirable physical, chemical, 
physiologic or emotional changes are produced. 

3. Stimulation with ephedrine or other drugs 
is not necessary. 

4. It is easy to administer and the need for 
mixing drugs with solutions or spinal fluid is 
eliminated. 

. 5. The duration of anesthesia in the ano- 
rectal area is one hour or longer, frequently 
one and a half hours. 

6. The effective use of the lower extremities 
is usually recovered within one hour. 

7. The quantity of the preparation may be 
reduced to contain 14 mg. of procaine when it is 
certain that the contemplated proctologic pro- 
cedure will not require more than ten minutes 
after which period the patient maj'' effectively 
use his lower e.xtremities. 

8. To secure satisfactorj' results it is impor- 
tant that adequate preliminary cerebral seda- 
tion be obtained and that absolutely sterile and 
meticulous technic be observed throughout. 

references 

I. CAR.MEL, A. Gerson. Discussion, symposium on 
ancfthesia. Tr. Ain. Proc. Soc., pp. 161-162, 1937- 

American Journal oj Surgery' 



147 


Carmel — Spina! Anesthesia 


2. Carmel, A. Gerson. Modern surgical treatment of 

hemorrhoids and a new rectoplasty. Am. J. Surg., 
75:320-324,1948. 

3. Carmel, A. Gerson. Hemorrhoids (Anorectal 

Phlebopathy). Thesis for M. Med. Sc. (Proc- 
tology), I'niversity of Pennsylvania, 1948. 

DISCUSSION OF PAPERS BY DRS. LUNDY, CRIGLER 
AND CARMEL 

F. W. Clement. In the majority of cases the 
anesthesia for rectal surgery presents no undue 
problem. We have always heard or been taught 
that no single agent or method was suitable for 
each and every case. Each method has its indica- 
tions and its contradictions. There arc numerous 
variables involved such as the patient, surgeon, 
anesthetist, hospital facilities and so on. The prime 
requisite from the surgeon’s point of view is 
adequate muscular relaxation. 

If the surgeon is in a position where he has to do 
his own anesthesia, he will select some agent or 
method which is simple and which requires the 
least amount of supervision. That will probably be 
caudal anesthesia or spinal. 

If the surgeon has the service of an anesthetist, 
the choice will largely be left to the anesthetist 
who, in turn, will favor some method or agent with 
which he is most familiar and with which he has 
obtained the best results from the viewpoint of 
both the surgeon and the patient. 

My choice would be first the caudal anesthesia. 
1 prefer caudal to caudal plus sacral because from 
the patient’s view’point it means one needle stick 
instead of seven or eight. In my hands it would 
mean a good many more than seven or eight. If 
one were unable to get into the caudal canal for 
any reason, of course the transsacral could be used. 

The next choice would be low spinal anesthesia 
and, for abdominoperineal work, continuous spinal 
or a single dose of spinal to which epinephrine has 
been added to prolong the anesthesia. 

The third choice would be inhalation. Of that 
choice I would prefer nitrous oxide oxygen plus 
curare, especially if the cautery were to be used. 

The next would be gas-ether and the last open- 
drop ether; then comes intravenous anesthesia. In 
our experience we are beginning to prefer nembutal 
intravenously to pentothal because it is more 
convenient; it is already mixed and ready to give. 
I think it gives a little more profound anesthesia 
and there is definitely less tendency for laryngeal 
spasm. 

A combination of inhalation plus intravenous 
plus curare for relaxation is a very popular and 
widely used form of anesthesia today. The last 
choice would be local anesthesia. 

Time docs not permit going into all the indi- 
cations and contradictions, etc., for each agent. Just 
reported were three excellent papers on different 
methods of anesthesia for anorectal surgery, all of 

Jannarx', 1950 


which give excellent results. As long as excellent 
results are thus obtained, I see no reason for these 
men changing to any other method. 

There is no question that an anesthetic ordi- 
narily considered dangerous when expertly given 
may be much safer and better for the patient than 
the use of some agent ordinarily considered safe 
which is inexpertly given. The same old adage 
holds for this type of anesthesia as for all “that no 
anesthetic is any safer than the person who 
gives it.” 

R. I. Brashear (Columbus, O.): Anesthesia in 
rectal surgery is like golf. Each man in a foursome 
may use a different club to reach the greens and 
likewise the same club would not be used under all 
circumstances. It seems that there should be a 
certain amount of flexibility in anesthesia for rectal 
surgery. Every now and then it becomes necessary 
to substitute some other anesthesia in place of your 
favorite one. 

Dr. Crigler reports on a large series of patients 
anesthetized with sodium pentothal. I think that 
sodium pentothal has a definite place in rectal 
surgery, especially for its use in rectal abscesses, 
removal of fecal impactions or in patients that will 
not tolerate postoperative finger dilatations. For 
general operative procedures, with the patient 
in the prone position, pentothal does not seem as 
safe as it should be. Since it is a respiratory de- 
pressant, patients sometimes have difficulty in 
breathing and are more susceptible to laryngo- 
spasm. It has been my experience that bleeding is 
much harder to control when operating with 
pentothal than when using a spinal, transsacral or 
caudal anesthesia. Relaxation of the sphincter with 
pentothal is not as profound or as constant as the 
other types of anesthesia under discussion. I 
appreciate the ease with which pentothal is given 
and the time that might be saved but I also appre- 
ciate the fact that it might be given with too much 
ease. 

Dr. Crigler states that the average time his 
patients are in the operation room is twenty 
minutes. On the average my cases run thirty to 
forty-five minutes and I enjoy having an anesthesia 
that will give me perfect relaxation during the 
entire operation. One sodium pentothal anesthesia 
could be eliminated if the large rectal packs were 
not used. Five or ten minutes more in surgery 'svill 
prevent as much postoperative bleeding as the 
rectal packs. 

Dr. Carmel suggests the use of small dosage 
spinal anesthesia, the action of which is prolonged 
by the use of 1 : 20,000 epinephrine; duration of one 
to one^ and a half hours is claimed. The relaxation 
following spinal is most excellent. The drawbacks 
to spinal anesthesia are as follows: postoperative 
headaches which at times are quite troublesome; it 
wears off suddenly; urinary retention is more 
troublesome than in transsacral and caudal 



148 


Carmel — Spinal Anesthesia 


anesthesia; difficulty in getting some patients to 
accept it; and if any neurologic complications do 
occur you will never hear the last of them. 

Most of the mentioned drawbacks to spinal 
anesthesia can be eliminated by the use of trans- 
sacral and caudal blocks. There are no postopera- 
tive headaches, there is less urinary retention, it is 
of longer duration and wears off slowly. Also, most 
patients will aecept it and neurologic complications 
are practically nil. 

Caudal anesthesia may be given just as quickly 
as a spinal anesthetic and in some instance more 
rapidly. It may take a little longer for its action 
to be complete; it is usually complete in eight to 
ten minutes. 

For the past two years one-half of my patients 
have been operated upon under transsacral and 
caudal and one-half under caudal anesthesia except 
in those rare cases in which cither spinal or pento- 
thal were used. I can see no adt'antages of the 
transsacral and caudal over the plain caudal anes- 
thesia. Using 25 cc. of 2 per cent mct3'cainc the 
need for injection of the foramina may be dispensed 
with and some sore backs eliminated. If one 
quadrant should happen to be missed, this can be 
picked up with a little local anesthesia. Failures 
have been rare in my ten years of experience with 
caudals and I believe that failures are due to the 
placing of the anesthesia someplace other than the 
caudal canal. Warming of solution is usually 
helpful. 

If caudal anesthesia is good for the poor risk 
patient, why would it not be a good anesthesia for 
the average good risk patient? 

L. J. Hirschman (Traverse City, Mich.); 1 was 
privileged to be the guest of the British Section on 
Proctology at Newcastle-on-Tyne a number of 
years ago and the whole session was devoted to the 
subject of hemorrhoids. 

I wish to confine mj'- remarks entirely to this 
question of caudal anesthesia. I think we are in 
agreement that we use all types of anesthesia in 
our practice. I am not going to give you any 
figures, but I have been using caudal anesthesia in 
rectal surgery for over forty years. We have done 
quite a few cases; I will not try to tell you how 
many. However, it is the anesthetic of choice in our 
rectal surgery. 

There are three people to be considered in anes- 
thesia and in surgery: first, the patient, second the 
surgeon and third the anesthetist because the 
surgeon should have a good deal to say as to about 
what kind of anesthesia he wants used in a given 
case. 

We certainly get fewer cases requiring catheter- 
ization from caudal anesthesia. We do not claim to 
get 100 per cent from any type of anesthesia but 
we do get better than go per cent. The only failures 
we seem to have occur in the amphitheater before 
a clinic! 


We give not over 30 cc. of i per cent- in many 
cases and then wc^add sterile water until the piston 
pressure tells us that the canal is well filled. We 
believe by that that we have reached all of the 
sacral nerves and we also have pressure added to 
chemical anesthesia. 

We also believe that posture has a good deal to 
do with it. I am awfully sorrj'^ that so many men 
around the country employ that position known 
as the jackknife or prone position, but they do. It 
has the disadvantage in giving anesthesia as well 
as in operating that it does interfere with the 
patient’s respiration; a good many complain about 
it afterward. I am a great advocate of the Sims’ 
position, left or right, whichever you wish, because 
the patient is more comfortable and so is the 
surgeon. The surgeon can sit down while he works. 
He is less fatigued. The exposure is good and anes- 
thesia equally so. 

A good many patients still think when you speak 
of caudal anesthesia that means spinal anesthesia. 
We always have to give an anatomic demonstration 
to prove it is not. 

Here the obstetricians recently caught up with 
us and immediately they publicized caudal anes- 
thesia for obstetrics. We poor proctologists have 
been using it for forty years. We have to tell the 
ladies that it is the type of anesthesia used for child- 
birth and then everything is all right. 

In those few failure cases, as has been reported 
by my good friend, Dr, Brashear, local or regional 
anesthesia is employed as a supplement. We always 
give our patients a long-lasting oil anesthetic and 
we do not have much difficulty. We certainly never 
would give pentothal to remove a pack. 1 thought 
that rectal packs went out about the time that 
slavery was abolished. Mj’’ good friend, Sam Gant, 
once said, “You know, I am a surgeon; I am not a 
taxidermist. I don’t stuff the bird like the taxi- 
dermist does.” 

Marion C. Pruitt (Atlanta, Ga.): I, also, 
would like to add my condemnation of the use of 
the whistle. Rectal packs have caused more pain, 
urinary retention, abdominal distention and 
general discomfort to the patient than any other 
one thing in anorectal surgery. I would like to add 
the use of one other agent as a prolonged post- 
operative anesthetic for prolonged postoperative 
anesthesia. For the last six or eight j'ears I have 
been using a 20 per cent aqueous solution of ethjd 
alcohol injected into the external sphincter muscle 
using about four to six drops injected in about six 
or seven areas around in the muscle or about to 
3 ^ inch apart. Soon after my first report on this 
subject someone wrote me from a distant city and 
asked, “How many cubic centimeters did you saj' 
you used in each puncture?” 

I would like to emphasize the fact again that if 
you are going to use 20 per cent ethyl alcohol as 
your prolonged anesthetic agent, it is to be injected 

American Journal oj Surgery 



149 


Carmel — Spinal Anesthesia 


into the external sphincter muscle not more than 
four to live drops in each point and not more than 
five to seven points around the anus. 

The duration of the ethyl alcohol lasts from four 
to twenty-one days. It has all the advantages of 
the other prolonged anesthetic agents and it does 
not cause any edema. The thing that causes most 
of the discomfort in postoperative cases is the 
muscular spasm, the contraction or grabbing of the 
sphincter muscle. The injection of ethyl alcohol 
eliminates that. It also aids in preventing the 
retention of urine as a postoperative condition. 

For about eight years I have used sodium 
pentothal for anorectal surgery in about 6,000 or 
7,000 cases. I use the jackknife posture. The 
amount of anesthetic agent used has been from 
3 ^ to 2 mg. I have not had any fatalities or serious 
complications in this series of cases. It is a common 
and, I think, comparatively safe anesthetic used 
in my town. 

Raymond L. Murdoch (Oklahoma City, Okla.): 
In connection with Dr. Crigler’s paper I want to 
state my conclusions developing over a period of 
years that the injection of either aqueous or oil 
so-called long-lasting anesthetic solutions post- 
operatively is not only unnecessary but sometimes 
causes infections. This complication is often more 
serious than the condition for which the original 
operation was performed and is definitely more 
difficult to explain. Many of the seasoned members 
of this group have expressed similar conclusions to 
me. Referring to general injection of hemorrhoids 
more than to postoperative anesthetic injections, 
we learn by word of mouth about the infrequent 
case of complications so severe that they do not 
get into the statistics. Because the tenor of the 
papers so far on this program has been favorable to 
injections with discussion limited and because at 
this historical meeting we have the greatest number 
of newcomers ever to be in attendance, I want to 
express the seasoned opinion of a considerable part 
of the membership that great caution should be 
used with respect to injections when or if they are 
used at all. 

John S. Lundy (closing): I think that it might 
be fair to defend myself a little bit even though 
Louie Hirschman trained me over in Harper 
Hospital in 1920. 

The reason I use transsacral block is so that 1 
will not use a solution that is stronger than i per 
cent. If you have a fatality, you have to do an 
awful lot of cases to dilute it enough to justify it; 
and 2 per cent solution injected in a vessel can 
produce a fatal convulsion. The caudal canal is full 
of veins and you are bound to get into them sooner 
or later. 

R. E. Crigler (Ft. Smith, Ark.); As you know. 
Dr. Curtice Rosser some three or four years ago 
was the first to advocate the use of gellfoam and 
oxycel in order to eliminate the use of rectal packs. 

Januanr, ig^o 


We have gotten around to using the oxycel and 
maybe sooner or later we will give up the applica- 
tion of rectal packs. 

Dr. Murdock brought up the question concerning 
the tragic results from the use of oil injections. As 
was mentioned in the beginning, we tried to keep 
an accurate tabulation of any and all complications. 
So far we have had no complications whatsoever 
following the use of this oil anesthetic infiltrating 
the perianal region. 

A. Gerson Carmel (Cincinnati, 0 .): Great 
strides in anesthesiology have been made in the 
past two decades. No one has played a more 
important role in this regard than has Dr. Lundy. 
Our distinguished chairman stated that he admired 
the courage of surgeons who dared to discuss anes- 
thesia. However, many surgeons have investigated 
and written on anesthesia. For example, W. Wayne 
Babcock made important contributions to the 
literature on spinal anesthesia. The Transactions 
of the American Proctologic Society contain 
numerous articles by its members on the choice of 
anesthetic agents in proctologic surgery. The 
recognition of problems serves as the impetus for 
their solution. When I began to practice proctology 
in my community, inhalation anesthesia was the 
rule. I believed that it was too big an anesthetic, at 
least for certain poor risk patients. 

Our president, Harry Bacon, was my junior 
instructor during my training period in Phila- 
delphia, He was just as indefatigable then as he is 
now. He had me spend many a late afternoon in 
the anatomy department at Temple University 
dissecting and studying the sacral and coccygeal 
areas of cadavers in order to learn to perform 
caudal and transsacral anesthetics. Subsequently, 
at the Mayo Clinic I admired the perfection with 
which caudal and transsacral anesthetics were 
administered. When I came home, I tried to 
emulate the methods I had seen Drs. Lundy and 
Buie et al. use so successfully. My first ten cases 
were uniformly satisfactory and I was highly 
pleased with the procedure. None of the anes- 
thetists in my community were employing caudal 
or transsacral anesthesia and it was seldom that 
spinal anesthetics were used. My practice has been 
to have on hand an able anesthetist. Occasionally 
one would state that he had been trained in the 
administration of caudal blocks. The failures in the 
hands of my anesthetists were well above 20 per 
cent. As time went on my own failures began to 
accumulate and I decided that caudal and trans- 
sacral anesthesias were not the methods of choice 
for anesthesia in Cincinnati. I wish to emphasize 
that we have some highly capable anesthesiologists 
there. 

Opportunitity for developing the spinal anes- 
thesia described presented itself at Longview 
Hospital in Cincinnati, Surgery was not being 
performed there and anesthetists were not avail- 



150 


Carmel — Spina] Anesthesia 


able. The problem, if surgical proctology was to be 
done, was to develop an anesthesia which would be 
safe, easy to administer and which would require 
the minimal amount of supervision during and 
following the operation. Further encouragement 
was provided when Curtice Rosser told me in 
personal conversation that he was emploj'ing 50 
mg. of procaine for spinal anesthesia and was 
highly pleased with it. He urged me to continue 
working with small doses of anesthetic solution. 

Someone has stated that the type of anesthesia 
does not make much difference in a proctologic 
patient. While this may be frequently true, the 
choice of the anesthetic agent in some instances 
becomes exceedinglj'^ important and may be the 
difference between life and death. Examples arc 
poor risk hypertensive and severe cardiac patients 
suffering with pain from anorectal lesions that arc 
unrelieved by local therapy and narcotics; the 
severe pain, associated straining and loss of rest 
may be aggravating the cardiac condition. In such 
instances anesthesia with small doses of the pro- 
caine-epinephrine solution has thus far been 
innocuous in contrast to undesirable complications 
that have been observed with other forms of 
anesthesia. As little as 14 mg. of procaine in the 
epinephrine combination may be employed if the 
procedure is to last only ten or fifteen minutes. It 


may be well to point out that the danger of a pro- 
caine reaction with the minute doses of drug used in 
spinal anesthesia is far less than that with other 
methods which require much larger quantities of 
procaine. Local infiltration may be excellent but 
it, too, has noteworthy disadvantages in proctologic 
surgery. It is frequently advisable that one finger 
be inserted into the anal canal as a guide during the 
infiltration. When a tender lesion is present, this 
will cause great pain and straining until the anes- 
thesia has become effective. While topical applica- 
tions may somewhat lessen the tenderness in an 
anal ulcer, they do not eliminate the pain induced 
b3' pressure. Extensive scar tissue in fistula cases 
interferes with the distribution of the anesthetic 
solution. In the presence of active infection local 
infiltration is not desirable. Furthermore, the 
degree of muscular relaxation is not equal to that 
which is obtained after spinal anesthesia. 

An experience in anesthesia with 1,200 cases maj’ 
not be a large one. However, the results over manj>- 
3'cars have been so favorable that it is believed a 
report should be made to amplify the cursory 
remarks made on the subject in my presentation to 
this Society' in 1947 on the surgical treatment of 
hemorrhoids. 1 agree in general with all the partici- 
pants in this symposium that the methods of 
anesthesia mentioned arc valuable and that all are 
applicable in proctologic surgery. 




American Journal 0/ Surgery 



SURGICAL IMPORTANCE OF THE COMPOSITE 
LONGITUDINAL MUSCLE OF THE ANAL CANAL, 
EXTERNAL SPHINCTER AND LEVATOR ANI MUSCLES 

C. Naunton Morgan, f.r.c.s. (Eng.) 

London, England 


I T is the purpose of this article to bring to 
your notice the importance of three 
muscles in the surgery of the anorectal 
region and perineum. 

The composite longitudinal muscle of the 
anal canal is formed by the fusion of the pubo- 
rectalis portions of the levator ani muscles with 
the longitudinal muscle coat of the rectum 
as the bowel passes through the pelvic dia- 
phragm. The muscle surrounds the anal canal 
and lies between the internal sphincter formed 
by the circular muscle coat of the rectum and 
the external sphincter. The main insertion 
of the muscle is by means of fibro-elastic fibers 
into the modified skin of the anal canal between 
the lower border of the internal sphincter and 
the inner and upper aspect of the subcutaneous 
external sphincter. Thus is formed the anal 
intermuscular depression. Thin filaments of the 
longitudinal muscle also pass through the 
innermost portion of the subcutaneous external 
sphincter and are attached to the perianal skin 
(the corrugator cutis ani muscle). In addition 
there is one constant outward extension of its 
fibro-elastic fibers between the subcutaneous 
and the two deeper portions of the external 
sphincter muscle. This septum extends outward 
across the ischiorectal fossa as far as the ischial 
tuberosity, dividing the fossa into a sub- 
cutaneous perianal space and the ischiorectal 
space. 

The longitudinal muscle is of surgical impor- 
tance for the following reasons: First, by virtue 
of its formation, attachments and extension 
this muscle enables the puborectalis to take an 
important part in the anorectal muscular 
architecture. Second, its outward extension 
across the ischiorectal fossa tends to prevent 
spread of infection from the perianal space 
upward into the ischiorectal space. Infection 
in the perianal space is responsible for 75 per 
cent of all fistulas, namely, the low anal variety 
whose internal opening lies at the anal inter- 
muscular depression. I would remind you, 

Jamian % 7950 i 


however, that infection in the ischiorectal 
space commonly involves the perianal space. 
So far we have found no clinical evidence ol 
extension of infection upward along the main 
portion of this muscle as described by Courtney. 
Third, the composite longitudinal muscle of 
the anal canal prevents eversion of the lining 
of the anal canal and c.xtrusion of an internal 
hemorrhoid. It is only when the muscle is 
stretched beyond its limits that a prolapsed 
internal hemorrhoid remains permanently pro- 
lapsed, resulting in the formation of the intero- 
external variety of hemorrhoid. 

ST. mark’s hospital operation for 

HEMORRHOIDS 

The method of hemorrhoidectomy which we 
emplo3’’ at St. Mark’s Hospital has stood the 
test of time. Its correct performance depends 
on the demonstration and preservation of the 
main portion of the composite longitudinal 
muscle as this passes between the internal and 
subcutaneous external sphincters. 

Following complete exposure of the pile 
masses and recognition of the linings of the 
anal canal and the rectal mucosa, the skin tag 
and e.xternal hemorrhoidal plexus associated 
with the internal pile is dissected eleanE^ olT 
the subcutaneous external sphincter. Thin 
filaments of the longitudinal muscle passing 
through the subcutaneous external sphincter 
will require division until the inner border of 
this muscle is clearly seen. Here the dissection 
ceases and the main portion of the longitudinal 
muscle is readilj'^ identified as it passes to the 
anal intermuscular depression. Ligation of the 
internal hemorrhoid is carried out at the highest 
point of its pedicle b^”^ firm downward traction 
of the rectal mucosa bj^ an assistant as the knot 
is tied. This downward traction ensures com- 
plete removal of the pile, yet it will be found, 
because the undivided longitudinal muscle had 
been incorporated in the ligature, that the 
ligatured pedicle will not retract upward into 



152 


Morgan — Composite Longitudinal Muscle 


the rectum leaving a large raw area in the anal 
canal. The lower edge of the undisturbed 
internal sphincter, lying between the longi- 
tudinal muscle and the rectal mucosa, prevents 
any retraction of the ligatured pile pedicle. 

THE DEEP and SUBCUTANEOUS PORTIONS OF THE 

EXTERNAL SPHINCTER 

The deep e.xternal sphincter fuses with the 
puborectalis and with it forms the anorectal 
ring. The anterior portion of this anorectal 
muscle ring is completed by the deep part 
of the external sphincter while laterally and 
posteriorly it is formed by the puborectalis 
U-shaped muscle sling. It has been repeatedly 
confirmed that preservation of a small but 
complete portion of this ring will allow control 
of normal feces. Location and preser%'ation 
of the anorectal ring is of first importance 
during operations for high fistulas. 

The most superficial portion of the three 
parts of the external sphincter, namely, the 
subcutaneous portion, is the only muscle which 
actually surrounds the anal orifice where it can 
be seen and felt under the perianal skin. This 
muscle, as Blaisdell has pointed out, is impor- 
tant in the pathogenesis of fissure-in-ano. 
Failure to relax during defecation owing to 
spasm or fibrosis will lead to the production of a 
fissure in the middle line in the depression 
formed by the Y-shaped superficial portion of 
the external sphincter. 

In the base of a chronic fissure the white, 
transversely placed fibers of the muscle can be 
seen and indicate the need for operative treat- 
ment. Division and maybe excision of this 
portion of muscle are necessary. In the base 
of a more recent fissure the pinkish fibers of the 
corrugator cutis ani muscle, which run radially 
toward the anus, will be seen. In cases of fibrous 
anus with or without a fissure the lower edge 
of the internal sphincter may be fibrosed and 
will require division. 

SURGICAL LANDMARKS 

The Anorectal Ring and Anal Intermuscular 
Depression. The anorectal ring and anal 
intermuscular depression can be palpated with 
the finger and their demonstration with 
certainty at operation is essential. These two 
landmarks can also be seen. The anorectal ring 
is visible through a proctoscope; and because 
the highest part of the internal hemorrhoidal 
plexus lies just above it, it is a guide to the 
point for the first injection when using the sub- 


mucous injection method for the treatment 
of internal hemorrhoids. The anal intermuscu- 
lar depression can be seen on a prolapsed third 
degree internal hemorrhoid. 

The Levator Ani Muscle. For practical pur- 
poses the muscle may be considered as con- 
sisting of two main portions, each with a 
difrerent function: the pubococcygeus with its 
especially developed portion, the puborectalis, 
sphincteric, while the iliococcj^geus together 
with the coccygeus act as a support for the 
basin-like pelvic outlet. 

In addition to the fact that the puborectalis 
portion of this muscle plays such an important 
part in the formation of the anorectal ring, the 
levators ani are concerned in the formation of 
the boundaries of the ischiorectal space and 
thus with the spread of infection in this area. 
Further, knowledge of the relation of its two 
main portions to one another and to the rectum 
helps the surgeon in performing perineal dis- 
section of the rectum. 

The Pubococcygeus. This is the most an- 
teriorl}' placed portion of the muscle and it 
surrounds the visceral canals as they emerge 
through the pelvic aparture. It takes origin 
from the back of the pubis and anterior part 
of the white line and its fibers pass directly 
backivard on either side of the prostate or 
vagina and the rectum to gain insertion in a 
V-shaped manner into its own raphe behind 
the rectum. As the muscle passes backward it 
undergoes a twist so that instead of presenting 
superior and inferior surfaces and an anterior 
and posterior border, its surfaces become in- 
ternal and external while its anterior border 
becomes the inferior border. The internal 
surface lies in intimate contact with the bowel 
wall while the external surface forms the inner 
wall of the ischiorectal space. 

The inferior border is thicker and more 
vascular than the rest of the muscle and the 
fibers of this portion do not become attached 
to the common raphe but form a continuous 
sling behind the anorectal junction. This por- 
tion of the pubococcygeus is the puborectalis. 

Iliococc^rgeus. This portion of the levator 
arises more posteriorly from the lateral pelvic 
wall to pass to its insertion into the anococ- 
cygeal raphe. Its fibers thus pass downward and 
inward and do not come into intimate relation- 
ship with the visceral canal and are usually 
poorly developed. The muscle is inserted into 
the anococcygeal raphe which lies below the 
raphe of insertion of the pubococcygeus. This 

American Journal oj Surgery 


Morgan — ^Composite Longitudinal Muscle 153 


latter muscle tlius overlaps the iliococcygcus 
from above. 

The Ischiorectal Space. The shape and 
boundaries of the ischiorectal space are governed 
not only by the shape and tilt of the bony 
pelvis but also by the differing positions and 
planes of the pubococcygeus and iliococcygcus 
as they pass across the pelvic outlet. The 
pubococcygeus lies on the inner wall of the space 
and the iliococcygcus forms its arching roof. 
The outer wall is the obturator internus covered 
b^’^ its fascia. 

The origins of these two portions of the 
levator together with the obturator internus 
approach one another at the back of the pubic 
bone and thus is formed the anterior extension 
of the ischiorectal space which lies above the 
triangular ligament. 

The ischiorectal space lies anteroposteriorly 
and is wedge-shaped; the apex of the wedge is 
situated anteriorly behind the pubis and its 
base posteriorly in the region of the sacro- 
sciatic ligament and the inner edge of the 
gluteus maximus muscle. The floor of the space 
is formed by skin and fat of the perianal space 
but anteriorly the forward extension passes 
forward above the transverse perineal muscles 
and the triangular ligament so that these 
structures form its floor. 

Owing to the tilt of the pelvis the coccyx lies 
in the same horizontal plane as the deepest 
part of the ischiorectal space including its 
anterior extension and the space becomes super- 
ficial posteriorly. 

Whatever the method of spread of infection 
may be from the anal canal to the ischiorectal 
space, we have consistently found that a fistula 
extending into this space forms a regular 
pattern which is apparently brought about by 
the conformation of the pubococcygeus and 
puborectalis. 

The main track of an anorectal fistula 
extends upward parallel and outside the 
muscles surrounding the anal canal to the roof 
of the ischiorectal space. Here the anterior 
extension of the fistula passes forward to the 
pubis above the triangular ligament. There 
may be an extension of the fistula to the 
opposite side and this will be found to pass 
along the sling fibers of the puborectalis. This 
track lies below the anococcygeal raphe but 
above the coccygeal origin of the superficial 
external sphincter. When the opposite ischio- 
rectal space is involved, a similar pattern of 
extensions may be found on this side also. 

Jamiary, ig$o 


Inllammatory induration spreading along and 
partially in the fibers of the puborectalis may 
give rise to the erroneous impression that the 
submucous space of the reetal wall is involved 
in the inflammatory process. Fortunately, in 
these cases the internal opening into the bowel 
lies below the level of the anorectal ring. 

EXCISION OF THE RECTUM PERINEAL 

DISSECTION 

A clear conception of the different planes of 
the two main portions of the levator ani muscles 
and their relation to the rectum will greatly 
aid the surgeon in performing this operation. 
With the patient in the lithotomy position and 
following removal of the coccyx, the forefinger 
is inserted in an anterior and outward direction 
above the coccygeus and iliococcygeus between 
these muscles and the fascia of Waldeyer. It 
will be found that the finger can readily be 
made to re-enter the ischioreetal fossa above 
the anterior edge of the iliococcygeus. The 
finger has in fact passed between this edge 
of the muscle and the superior edge of the 
puboeoccygeus. 

When the coccygeus and iliococcygeus have 
been divided on either side, the whole extent of 
Waldeyer’s faseia is seen and also divided. 

In the anterior part of the wound the pubo- 
coccygei, which closely embrace the rectum, 
will be seen extending above the transverse 
perineal muscles and the triangular ligaments. 
The finger is now inserted above the superior 
edge of this muscle and its greater part sepa- 
rated from the lateral aspeet of the rectum and 
divided. The inferior edge of the pubococ- 
cygeus on either side remains undivided. This 
undivided portion is the puborectalis and it 
will be remembered that this portion of the 
muscle fuses with the longitudinal muscle of 
the reetum. When the greater part of the 
puboeoccygeus on either side of the rectum has 
been divided, the prostate can readily be 
palpated. By palpating the prostate gland 
between the finger and thumb its apex can be 
located and now the difficult anterior disseetion 
commenced. 

The plane of dissection is kept behind the 
transverse perineal muscles as they meet in 
the middle line. The puborectales are defined 
and divided well away from the anterior rectal 
wall close to the sides of the prostate. The 
longitudinal fibers of the reetal wall whieh pass 
fonvard and upward to the prostate, the recto- 



154 


Morgan — Composite Longitudinal Muscle 


urethralis muscle, are identified and divided, the rectum a clear conception of the foregoing 

The division of these longitudinal fibers reveals muscles is necessary. 

the line of cleavage between the back of the i i tj i-i .. .. -u » ^ n 

, , ° I should like to pay tribute to my colleague, 

prostate and the rectum. . E. T. C. Milligan, of St. Mark’s Hospital, London, 

For the teacmng of proctology and for satis- Gorsch, Levy and Courtney in this great 

factory operative treatment of hemorrhoids, country. Their names will always be associated 

fissure, high level fistula and for operative with study and research into the surgical anatomy 

precision in performing perineal dissection of of the anorectal region. 




American Journal oj Surgery 



ANATOMY OF THE PELVIC DIAPHRAGM AND 
ANORECTAL MUSCULATURE AS RELATED 
TO SPHINCTER PRESERVATION IN 
ANORECTAL SURGERY* 

Harold Courtney, m.d., 

Syracuse, New York 


S PHINCTER preservation or the main- 
tenance of anal continence is of major 
importance in surgery of the anorectum 
whether it be fistula surgery or a pull-through 
operation for bowel resection. The fundamental 
requirement in sphincter preservation is an 
accurate knowledge of the detailed anatomy of 
the pelvic diaphragm and its related structures. 

During a study of the muscles and fascia of 
the pelvis, especially as related to the spread 
of infection by contiguity and the preservation 
of the anorectal sphincter musculature (carried 
out more minutely perhaps than formerly), 
several details heretofore apparently unde- 
scribed and anatomic relationships in disagree- 
ment with those of other investigators were 
found. 

A review of the literature on this subject 
discloses outstanding recognition of the investi- 
gations of HolP® and Thompson.-^ The ana- 
tomic findings as revealed by this study often 
coincided with those of Roll rather than with 
those of Thompson. 

RESEARCH MATERIAL 

Pelves of eight human cadavers of the negro 
and white races, male and female, were dis- 
sected in detail and pelves of forty cadavers of 
the negro and white races, male and female, 
were surveyed in the laboratory while dissected 
by others. This description is based upon a 
dissection made from both the perineal and 
pelvic approach and a comparison of the 
dissection with sagittal, parasagittal and 
coronal sections. 

ANATOMY 

As the peritoneum and subperitoneal fat was 
stripped from the pelvis, the tendinous arch 
of the levator ani muscle stood out as a promi- 
nent landmark in the parietal portion of the 


pelvic fascia (Fig. i) e.xtending from the back 
of the symphysis pubis to the spine of the 
ischium. A definite, triangular-shaped pro- 
longation of the arch extended upward to the 
region of exit of the obturator vessels which 
pass from the pelvis through the anterior 
portion of the obturator foramen. The union 
of the parietal fascia covering the superior 
surface of the levator ani muscle with the 
visceral pelvic fascia was plainly visible as a 
densely thickened white line, the only white 
line of the pelvic fascia. 

Levator Ani Muscle. In discussing the sub- 
divisions and attachments of the levator, the 
terminology used by earlier writers will be 
followed to avoid adding to the confusion and 
misunderstanding which already exist. The 
names of the various parts of this muscle as 
used by Thompson and Roll refer to the names 
of the supposedly analogous muscles of the 
lower vertebrates and not necessarily to their 
points of origin and insertion in the human 
being. 

Thompson divides the levator ani into two 
main subdivisions: an anterior or pubic portion 
and a posterior or iliac portion. Roll, on the 
other hand, subdivides the public portion into 
a medial portion, the puborectalis, and the 
more lateral portion, the pubococcygeus. The 
posterior subdivision of the levator ani has been 
named the iliococcygeus by both writers. 

The dissections show the origin of the levator 
ani as follows: The puborectalis arises from (i) 
the back of the body of the pubis; (2) the more 
medial fibers also taking origin from the 
tendinous arch of the levator ani muscle; (3) 
the lateral puboprostatic ligament; (4) the 
inferior surface of the levator fascia and (5) 
the superior surface of the deep layer of the 
so-called urogenital diaphragm. (I find that the 
urogenital diaphragm as depicted in textbooks 


From the An.-itomical Laboratories of the Graduate School of Medicine of the University of Pennsylvania 
Tins paper received the Hermance Award given by The American Proctologic Society. ^ 


Januaiy, 7950 


155 



156 Courtney — Pelvic Diaphragm and Anorectal Musculature 



Fig. I. Drawing allowing superior view into dissected male pelvis, 
the rectum being displaced anteriorly and to the right (dissection 
by the author). , i , Levator muscle lateral to the point of division 
into a superior and an inferior layer. 2, Superior layer of the levator. 

3, Inferior layer of the levator. 4, The row of fossulcs with connect- 
ing tracts which extend inferiorly to the circumanal space (level of 
anal-intermuscular septum). 5, Superior layer of levator (ilio- 
rectococcygeus muscle) forming the superior boundary of the 
posterior levator space to the side of the rectum. 6, Longitudinal 
muscle layer of the rectum giving off fibers posteriorly which unite 
with fibers from the iliococcygcus and fibers from the levator fascia 
to form the iliorcctococcygeus muscle. 7, The lateral margin of the 
iliorectococcygeus muscle, the usual point of “break through” for 
abscesses from the posterior levator to the rcctorcctal space. 8, Ilio- 
rectococcygcus muscle forming the superior boundary of the posterior 
levator space posterior to the rectum. 

of anatomy and the literature is the result of often take a fibrotendinous origin from the 
sharp dissection and the artist’s imagination obturator fascia and pubic bone and can 
rather than anatomic fact; however, a descrip- be often traced as high as the arcuate line in 
tion of this structure is'not within the scope their origin. The line of union between the 

of this paper.) The pubococcygeus portion horizontal ramus of the pubis and the ischium 

arises from (i) the back of the pubis, lateral passes through the acetabulum and thus 
to the origin of the puborectalis; (2) the approximately 2.5 cm. of the anterior portion 
internal surface of the descending ramus of of the iliococcygcus muscle is found to take 
the pubis; (3) the obturator fascia and (4) the origin from the pubic bone as well as from the 
deep layer of the urogenital diaphragm. That ischium. To introduce the new term, iliopubo- 

portion of the tendinous arch of the levator ani cocej'^geus, would only lead to further confusion 

muscle overlying the pubococcygeus portion even though it is more accurate in description, 

appears to be free from any attachment whatso- As the individual muscle bundles of the 

ever to the underlying muscle. The iliococ- levator pass medially (Fig. i-i) they divide 
cygeus portion arises from (i) the obturator near the rectum into a superior (Fig. 1-2) and 
fascia; (2) the horizontal ramus of the pubis; an inferior (Fig. 1-3) layer (as viewed from 
(3) the tendinous arch of the levator muscle within the pelvis). This holds true for each 

and (4) the medial surface of the spine of the of the subdivisions of the muscle, namely, 

ischium. The most anterior bundles of fiber iliococcygcus, pubococcygeus and puborectalis. 

American Journal oj Surgery 


Courtney — Pelvic Diaphragm and Anorectal Musculature 


157 



Fjg. n. Drawing of mid-sagittal section somewhat schematic showing the relationships of the 
anorectum to the pelvic diaphragm and the anorectal musculature. A window has been cut through 
the lateral wall of tlie rectum layer by layer to show the relationships lateral to the rectum (dissec- 
tion by the author), i, Combined longitudinal muscle layer (anterior to the rectum). This layer 
is composed of the longitudinal muscle layer of the rectum, fibers from the levator fascia and 
fibers from both the superior and inferior layers of the levator. 2, Inferior layer of the pubo- 
rectalis muscle. 3, Arrow lying in the posterior levator space; this space surrounds the rectum 
like a horseshoe with the open end of the horseshoe toward the pubis. 4, Superior layer of the 
levator muscle. 5, Combined longitudinal muscle layer of the rectum (posterior to the rectum). 
6, Fiber from the superior layer of the levator to the combined longitudinal muscle layer of the 
rectum. 7, Inferior boundary of the posterior levator space formed behind the rectum by the 
superior surface of the coccygeal muscular raphe. 8, Iliorectococcygeus muscle formed by fibers 
from the iliococcygeus (striped), fibers from the longitudinal muscle layer of the rectum (smooth) 
and a few fibers from the levator fascia; this muscle forms the superior boundary of the posterior 
levator space behind the rectum. 9, Retrorectal space. 10, Coccygeal muscular raphe attaching to 
the tip and sides of the coccyx, ii. Posterior subsphincteric space (connecting the two ischio- 
anal fossae). 12, Puborectalis muscle (the sling of the puborectalis behind the rectum). 13, Fibers 
of the deep external anal sphincter muscle inserting into the skin along the anococcygeal skin 
sulcus. 14, Deep external anal sphincter muscle (posterior to the rectum). 15, Anal intermuscu- 
lar septum. 16, Subcutaneous external anal sphincter muscle. 17, Internal sphincter muscle 
(anal). 18, Fibers from the subcutaneous and the deep external anal sphincter muscles to the 
bulbocavcrnosus muscle, ig, Bulbocavcrnosus muscle. 20, The deep external anal sphincter 
muscle and the central tendinous point of the perineum. 21, Fiber from the combined longitudinal 
muscle layer of the rectum to the sphincter of the urethra. 22, Fiber from the combined longitudinal 
muscle layer of the rectum to the lateral puboprostatic ligament. 23, Obturator fascia. 24, Ana- 
tomic tract lying within the combined longitudinal muscle layer of the rectum e.xtending from 
the circumanal space (level of the anal intermuscular septum) below to the fossules in the retro- 
rectal space above. 25, Rectal stalk. 


It was found that the individual muscle bundles 
overlap each other in a staggered arrangement 
so that as one passes anteriorly from the back 
of the pelvis to the front, the anterior edge of 
the most posterior muscle bundle is overlapped 
by the posterior edge of the muscle bundle 
anterior to it. This arrangement occurs 

January, ig^o 


throughout the entire structure of the ilio- 
coccygeus muscle until the anterior edge is 
reached. At this point it was noted that the 
anterior edge of the iliococcygeus muscle over- 
laps the posterior edge of the pubococcygeus 
(a reverse order) thereby raainng a definite 
division or landmark between the iliococcygeus 



58 


Courtney — -Pelvic Diaphragm and Anorectal Musculature 



Fig. III. Drawing of coronal section of dissected male pelvis, somewhat schematic 
showing the c.vtcnt of the posterior levator space posterior to the rectum and the 
manner in which the inferior layer of the levator winds itself around the rectum 
to form the deep c.\tcrna( sphincter muscle of the anus. The iliorectococcygcus 
muscle has been split in the posterior midline and the flaps turned upward. The 
wall of the posterior half of the rectum has been removed, with the exception of a 
few muscle bundles of the combined longitudinal muscle layer on each side and 
a block of the lower end of the internal sphincter muscle on the right. Tlic skin 
ofthe anal canal has been removed (dissection by the author), i, Iliorectococcygcus 
muscle. (Superior boundary of the posterior levator .space posterior to the rec- 
tum.) 2, Superior layer of the levator. 3, Inferior layer of the levator. 4, Levator 
muscle (lateral to the point of division into a superior and an inferior layer). 

5, Muscle bundle from the superior layer of the levator to the combined longi- 
tudinal muscle layer of the rectum. 6, Muscle bundle from the inferior layer of 
the levator to the combined longitudinal muscle layer of the rectum. 7, Circum- 
anal space. 8, Anal intermuscular septum. 9, Deep e.xtcrnal anal sphincter mus- 
cle. 10, Puborectalis muscle; inferior layer as it winds and entwines itself around 
the bowel to form the deep external anal sphincter muscle. 1 1 , Coccygeal muscu- 
lar raphe (inferior boundary of the posterior levator space, behind the rectum). 

behind and the pubococcygeus muscle in front. 

Thus from the observations made on each and 
every one of the specimens it was unnecessary 
to draw an imaginary line, as stated by Holl, to 
determine the point of division between the 
iliococcygeus and pubococcygeus muscles. In 
each instance the line of division between these 
two muscles was just anterior to the point of 
e.xit of the obturator vessels through the ante- 
rior portion of the obturator foramen. The 
staggered arrangement of the pubococcygeus 
and puborectalis muscle is reversed in relation 
to the anterior and posterior edges of their 
individual muscle bundles as compared to that 
of the iliococcygeus muscle. 

American Journal of Surgery 


The superior and inferior layers of the 
levator (iliococcj'geus and pubococcygeus por- 
tions) diverge from each other slightly, therebj" 
forming a “V-” or wedge-shaped potential 
space lying against and surrounding the rectum 
posteriorly and laterally, which I have named 
the “posterior levator space.”^’® 

As the superior layer of all three portions of 
the levator (iliococcj'^geus, pubococcygeus and 
puborectalis) comes in contact with the rectal 
wall, it gives off fibers which become fibro- 
tendinous and join with fibers from the levator 
fascia, both of which unite with the longi- 
tudinal muscle layer of the rectum to form a 
composite muscle layer, completely encircling 



Courtney — Pelvic Diaphrugm and Anorectal Musculature 


'59 



Fig. IV. Drawing of lateral view of dissected male pelvis showing the distribu- 
tion of the fibers of the levator and external anal sphincter muscles, i , Pubo- 
coccygeus muscle. 2 , Iliococcygeus muscle. 3, Coccygeal muscular raphe 
attaching to tip and sides of coccyx. 4, Posterior subsphincteric space lying 
between the coccygeal muscular raphe and the coccyx above and the posterior 
insertions of the deep anal sphincter into the corium along the anococcygeal 
skin sulcus below. 5, Posterior insertions of the deep external and sphincter 
muscle into the corium along the anococcygeal skin sulcus. 6, Deep external 
anal sphincter muscle formed from fibers of the puborectalis as it winds itself 
around the bowel. 7, Subcutaneous external anal sphincter muscle. 8, Super- 
ficial transverse perineal muscle (cut away from its insertion into the tuber- 
osity of the ischium). 9, ischiocavernosus muscle. 10, Fibers of the puborectalis 
muscle passing to the central tendinous point of the perineum and to the deep 
external anal sphincter muscle anteriorly. 1 1, Fibers of the deep external anal 
sphincter muscle passing to the central tendinous point of the perineum, thence 
to their various distributions. 12, Fibers from the pubococcygeus and iliococcy- 
geus muscles to the deep external anal sphincter muscle. 

the rectum below the level of the levator fascia, (longitudinal muscle fibers of rectum) they 
I have named this composite muscle layer the, form a more or less homogenous sheet or mass 
“combined longitudinal muscle layer of the of muscle, the individual fibers of which cannot 
rectum.” (Figs, n-i, 5 and 111-5, 6.) be separated by either sharp or blunt dissection. 

On a line approximately 1. 0 to 1.5 cm. from without injury to the configuration of the 
the rectal wall the levator fascia becomes muscle mass. In view of these findings it is 
densely adherent and inseparable, even by suggested that the new term, “iliorectococ- 
sharp dissection, from the superior layer of the cygeus muscle” (Fig. 1-5, 8) would be an aid 
iliococcygeus and pubococcygeus muscles. This to the understanding of the origin and relation- 
dense layer of fibrotendinous tissue is joined ships of this muscle and should be used in 
anteriorly by a few fibers from the superior place of the old terminology, “rectococcygeus 
layer of the puborectalis and also by fibers muscle.” 

from the longitudinal muscle layer of the Before describing the relationships of the 
rectum, to form a Y-shaped layer of muscle inferior layer of the iliococcygeus and pubo- 
which surrounds the rectum laterally^ and coccygeus muscles, I wish to describe the rela- 
posteriorly and passes backward to insert into tionships of the puborectalis muscle, 
the anterior surface of the coccyx and lower The puborectalis muscle (Fig. 11-2) is the 
segments of the sacrum. This muscle was strongest, best developed and most important 
tormerly cal ed the rectococcygeus muscle. It muscle of the pelvic diaphragm. Its superior 
was noted that whenever bundles of skeletal and inferior layers are in close apposition and 
muscle (levator) unite with visceral muscle are not easily differentiated. This muscle 
January, ig^o 



i6o 


Courtney — Pelvic Diaphragm and Anorectal Musculature 


passes posteriorly along the sides of the rectum 
(and vagina in the female), the individual 
muscle bundles winding and entwining with the 
corresponding muscle bundles from the opposite 
side of the pelvis to form behind the rectum 
what is commonly called the “sling of the 
puborectalis muscle.” (Figs. and iii-io.) 
This sling more or less anchors the rectum to 
the symphysis pubis. As these muscle bundles 
from both sides decussate behind the rectum, 
they pass to a slightly more inferior level where 
they entwine with the other bundles of the 
puborectalis coming from the same and oppo- 
site sides anteriorly, (by decussation through 
the central tendinous point of the perineum) to 
form the deep, external, anal sphincter muscle. 
(Figs. 11-14, 111-9 ^nd iv-6.) From this point 
these muscle fibers continue on to their various 
attachments. 

A mid-sagittal section through the rectum 
to the tip of the coccyx reveals that some of the 
puborectalis fibers split off from the others and 
pass posteriorly, some often becoming fibro- 
tendinous, to insert into the tip and sides of 
the coccyx. (Fig. ii-io.) The sling of the pubo- 
rectalis has no connection with the rectal wall 
posteriorly and laterally and is separated from 
the rectal wall by the aerolar tissue of the 
posterior levator space. (Fig. 11-3.) It appears 
that the posterior leyator space serves ana- 
tomically as a sort of bursa for the movement 
which normally takes place between the rectum 
and the sling of the puborectalis muscle. 
Posterior to the rectum the heavy mass of 
muscle fibers which make up the sling of the 
puborectalis and the deep external sphincter 
muscle are inseparable and appear in the 
sagittal section as one muscle mass. (Fig. 
1 1- 1 2, 14.) There is apparently no line of 
separation or division between these two por- 
tions of the puborectalis muscle. This offers 
further proof that the deep external sphincter 
muscle is formed by the continuation of the 
muscle bundles from the puborectalis muscle. 
Muscle bundles from the superior layer of the 
puborectalis are given off to the combined 
longitudinal muscle layer of the rectum ante- 
riorly and fibers from both layers pass into the 
deep external sphincter muscle, anteriorly and 
at its anterolateral margins both before and 
after decussation. Some of these muscle bundles 
pass anterior to the rectum and extend down 
to the central tendinous point of the perineum 
before going on to their various points of 


insertion. In the female these same muscle 
bundles pass between the rectum and vagina; 
also, fibers from the superior layer join those 
of the vaginal wall and pass inferiorly in the 
wall of that organ. 

A few muscle bundles from the inferior layer 
of the pubococcygeus and iliococcygeus muscles 
arc given off to the deep e.xtcrnal sphincter 
muscle. These muscle bundles are rather thin 
and nims^’’ and pass on to the external surface 
of the deep sphincter along its superolateral 
margin, eventually passing into the substance 
of the deep e.xternal sphincter between the 
heavier bundles of the puborectalis muscle. 
(Fig. xi-3a-a', b-b'.) The main or remaining 
portions of the inferior layer of the pubo- 
coccygeus and iliococcygeus muscles become 
fibrotendinous as thej’- pass posteriori}’- to insert 
into the tip and sides of the coccyx. The fibro- 
tendinous terminations of these two muscles 
form a tendinous sheet of fibers which attaches 
itself inseparably to the superior surface of that 
thinner, posterior portion of the puborectalis 
muscle which extends backward to insert into 
the tip and sides of the coccyx. This rather 
thin, fibromuscular mass was termed by 
Thompson, Moll and most other anatomists the 
“anococcygeal raphe.” According to the dis- 
, sections the term “anococcygeal raphe” is a 
misnomer because anteriorly, in no place does 
this tendinous raphe insert into or become 
attached to the anus, as described by these 
former writers. Anteriorly, this .raphe termi- 
nates by being attached to the superior surface 
of the puborectalis and gradually becomes lost 
as it passes down along the internal surface 
of this muscle forming the inferior boundary of 
the posterior levator space. It is suggested 
that the term “coccygeal muscular raphe” is 
more appropriate and should be used to refer 
to the raphe of the iliococcygeus, pubococ- 
cygeus and puborectalis muscles. (Figs, ii-io, 
iii-ii and 1V-3.) (Anatomists in the past have 
used the term “raphe” as applied to these 
fibers but this union of fibers does not form a 
“raphe” in the true sense of the word. It is 
feared that to introduce any new term would 
only add to the confusion that already exists.) 

External Sphincter Muscle of the Anus. My 
dissections do not justify the separation of the 
e.xternal sphincter muscle of the anus into three 
parts or layers; the subcutaneous, superficial 
and deep portions as described by Holl, 
Milligan and Morgan,'^ and others.®’’^ The 

American Journal of Surgery 



Courtney — Pelvic Diaphragm and Anorectal Musculature 



Fig. V. Drawing of perineal view of dissected male pelvis showing the relation- 
ships of the levator muscle and the perineal muscles to the deep and subcutane- 
ous external sphincter muscles of the anus, the attachments of the combined 
longitudinal muscle layer of the rectum to the dermis and the surface view of the 
central tendinous point of the perineum (dissection by the author). The arrow 
passes through the posterior subsphincteric space lying between the inferior 
surface of the coccygeal muscular raphe superiorly and the posterior attach- 
ments of the deep external sphincter muscle into the dermis inferiorly. In the 
enlargement at the right the skin has been stretched with three hemostats to 
illustrate the attachments of the subcutaneous and deep external sphincter 
muscles into the skin along the anococcygeal skin sulcus posteriorly and along 
the anal-scrotal raphe anteriorly; also the attachments of the layers of the com- 
bined longitudinal muscle layer of the rectum as they separate the individual 
muscle bundles of the subcutaneous sphincter and insert into the dermis, form- 
ing the corrigator muscle of the anal skin. The heavier layer forming the outer 
sheath of the subcutaneous sphincter muscle and separating it from the deep 
external sphincter muscle is shown as a heavy white line. Anteriorly the cut- 
off ends of muscle fibers from their skin attachments stand out. The manner in 
which muscle bundles from both the subcutaneous and deep portions of the 
external sphincter muscle (from the same and opposite sides) pass to their 
various attachments are shown as follows: to the raphe of the bulbocavernosus 
muscle, to help form the bulbocavernosus and to help form the superficial trans- 
verse perineal muscles. For clarity the muscle bundles inserting into the anal 
fascia and those traversing the fat of the ischio-anal fossa could not be illus- 
trated in this drawing (see line drawings). 


specimens show that the muscle is divisible 
into two portions, a subcutaneous and a deep 
portion (confirmed by Blaisdell).- The deep 
portion comprises the superficial and deep 
portions referred to by these earlier writers. 
These authors stated that the so-called super- 
ficial portion was the only part of the muscle 
attached to the coccyx and, therefore, referred 
to it as the coccygeal part of the external 
sphincter. My dissections do not agree with 
the aforementioned statements. In my dis- 
sections the terminations of the layers formerly 
described by these authors as superficial and 
deep are exactly the same both anterior and 
posterior to the anus. This fact supports my 
contention that these two layers comprise one 

January, ig^o 


muscle, namely, the deep portion of the ex- 
ternal sphincter muscle of the anus. 

Heretofore, textbooks and monographs have 
failed to show the exact relationship between 
the levator ani muscle and the external sphincter 
muscle of the anus. The relationship either has 
not been mentioned at all or has been stated 
in a casual manner. Milligan and Morgan 
stated that the fibers of the deep external 
sphincter and the levator were “in contiguit}'- 
with each other” and that “the posterior fibers 
intermingle with those of the puborectalis.” 
Blaisdell stated: “The external sphincter uni- 
formly blends imperceptibly with the levator 
ani, and tearing of the muscle is usually neces- 
sary to separation (except, of course, anteriorly. 



Courtney— Pelvic Diaphragm and Anorectal Musculature 


162 


anus 



subcci-taneous 
Sphincter ' 


of ":^L, 
ex.1 . 

S3SlSR< jj. 'f ^;>jn-biri<»c) 


,JE5p«v^';; ■* *s . 

<4- -’J^ v ^, ■ *j ^ \.:on‘biric 





• : - -'‘mlw^ 

' "■ •' '•, ’ ! iTiliic!/ 



Fig. VI. Retouched photograph showing the insertions 
of the subcutaneous sphincter, the deep sphincter and 
fibers from the combined longitudinal muscle layer 
of rectum into the corium along the posterior midline. 
An incision has been made through the skin in the 
midline (anococcygeal skin sulcus) and extended into 
the anal canal. The skin edges have been pulled apart 
and held in place by pins (dissection by the author). 


where the latter does not surround the anus).” 
My dissections not only confirm the statements 
of these authors^'” but in addition also show 
that the muscle bundles of the deep external 
sphincter originate from the inferior layers of 
all three portions of the levator, but principally 
from the inferior layer of the puborectalis mus- 
cle. Therefore, the deep external sphincter 
muscle should be considered as a part or con- 
tinuation of the levator ani muscle. 

Exposure of the external anal sphincter 
muscle by a linear incision radiating outward 
from the mid-lateral point of the anal verge 
reveals a mass of muscle approximately 8 mm. 
thick encircling the anus. By dissecting the 
individual muscle bundles free from the termi- 
nations of the combined layer of the longi- 
tudinal muscle which separate and surround 
them it was found that this mass of muscle 
consisted of the subcutaneous portion of the 
muscle described by other authors. How- 
ever, the relationships xvere different from those 


described by Holi, Milligan and Morgan. 
Lateral to the anus the subcutaneous portion 
of the muscle was made up of from six to eight 
thin, flat, ribbon-like bundles of muscle ap- 
proximately 8 mm. wide in a vertical direction; 
the flat side of the ribbon-like bands of muscle 
being parallel to the anal canal. As stated by 
these authors, the most medial bundles of fibers 
of the subcutaneous portion of the muscle were 
found to be in the same vertical plane as the 
internal sphincter muscle. (Figs, iii and vii.) 
However, the dissections show that the ribbon- 
like muscle bundles of the so-called superficial 
portion of the external sphincter muscle, as 
described by these authors, were directly' 
lateral to, and their lower borders only on a 
slightly higher horizontal plane than those of 
the musele bundles of the subcutaneous por- 
tion of the sphincter. (Figs, iii and v.) This is 
in disagreement with the aforementioned 
authors.'^’’^ Grossly, these two portions of the 
muscle appear as one mass, lateral to the anus. 
It is only bj' sharp dissection of each individual 
muscle bundle that I was able to determine or 
establish an anatomic separation between the 
subcutaneous and deep portions of the muscle. 
The septum of the combined layer of the longi- 
tudinal muscle passing between these two 
portions (subcutaneous and deep) is much 
thicker than those septa separating the in- 
dividual ribbon-like muscle bundles of the 
subcutaneous sphincter.. It is accompanied by 
numerous nerves and small blood vessels. 
(Figs. IV-7 and v.) On this basis I believe that 
the former writers were correct in separating 
the external sphincter muscle into two separate 
portions at this point. However, cognizance 
must be taken of the faet that the inferior 
margin of the deep portion of the e.xternal 
sphincter lies practically (only 2 to 3 mm. higher) 
on the same horizontal or subcutaneous level as 
that of the subcutaneous portion of the muscle. 
(Figs. IV and v.) 

The terminations or insertions of the subcu- 
taneous and deep portions of the e.xternal 
sphincter are similar in several respects: (i) 
Anteriorly, many of the fibers of both the 
subcutaneous and deep portions decussate and 
insert into the corium, (a) along the anal- 
scrotal raphe those of the subcutaneous portion 
inserting at or close to the anal verge and 
those of the deep portion passing farther 
anteriorly (Fig. v), (b) some of the fibers of 
the subcutaneous portion insert just lateral 

American Journal oj Surgery 


Courtney — Pelvic Diaphragm and Anorectal Musculature 163 


to the midline (Fig. iv), while some of the fibers 
of the deep part of the external sphincter be- 
come fibrotendinous and traverse the fat of 
the ischio-anal fossa to insert into the corium 
at more distant points (some of these fibers 
traverse the entire width of the ischio-anal 
fossa). Before decussating the muscle bundles 
usually break up into their individual muscle 
fibers, each carrying along with it a surround- 
ing layer from the longitudinal muscle layer 
of the rectum which, likewise, inserts into the 
corium along with the sphincter fibers. Thus a 
veritable network of fine decussating fibers is 
formed. (2) Fibers from both portions insert 
into the raphe of the bulbocavernosus muscle 
(Fig. v), those from the subcutaneous sphincter 
being attached closer to the anus. (3) Fibers 
from both portions coming from the same and 
opposite sides (that is, before and after decussa- 
tion) join with the fibers of the bulbocavernosus 
muscle to help form the structure of that 
muscle. (Fig. v.) (4) Fibers from both portions 
coming from the same and opposite sides pass 
laterally and form the superficial transverse 
perineal muscles which attach to the tuberosi- 
ties of the ischium on either side. (Fig. v.) (5) 
Posteriorly, fibers from both portions insert 
into the corium along the anococcygeal skin 
sulcus, the fibers of the subcutaneous sphincter 
inserting at or close to the anal verge, while 
those of the deep sphincter pass backward for 
a variable distance of approximately 4 to 5 cm. 
from the posterior anal verge. (Fig. vi.) It is 
probably due to the fact that each individual 
muscle fiber must be traced to its point of 
termination by blunt dissection and also that 
they apparently did not recognize the fibro- 
tendinous continuations of the individual fibers 
as such that led previous observers to state 
that the subcutaneous sphincter was circular. 
The so-called superficial portion of the external 
sphincter apparently has no attachment what- 
soever to the coccyx, as described by former 
writers."-*’’'®-*^ (6) Some of the fibers of the 
deep sphincter, after swinging around the 
anorectum, decussate by passing through the 
posterior subsphincteric space and in so doing 
help form the boundaries of this space as they 
pull the adjacent muscle layers apart. (Fig. ix- 
3b-b.') These fibers insert into (a) the anal 
fascia which they help create or (b) pass out- 
ward through the fat of the ischio-anal fossa 
(some fibers traverse the entire width of the 
fossa) before inserting into the corium at vary- 
ing distances from the anal verge. These same 

January, ig§o 


fibers often become fibrotendinous. (7) An- 
teriorly, after decussation heavy bundles of 
fibers of the deep sphincter also insert into, and 
help create, the anal fascia. 

I was unable to demonstrate a true anatomic 
space anteriorly, but clinically I have demon- 
strated to mjf own satisfaction, at least, that 
in anterior horseshoe fistulas the pathway of 
infection travels along the various muscle fibers 
which decussate through the central tendinous 
point of the perineum. Thus in anterior infec- 
tions which communicate with each other 
across the midline, the pathway of communica- 
tion usually occurs deep in the central tendin- 
ous point of the perineum rather than super- 
ficially as stated by some clinicians. 

Anatomists have found it necessary to name 
certain groups of muscle bundles for the pur- 
pose of description, often placing various names 
on different portions of a single muscle mass, 
as in the levator ani and the external sphincter 
muscles. 

This study indicates that the levator ani 
and deep external sphincter muscles should be 
considered, both anatomically and clinically, 
as one muscle. A study of the drawings (some- 
what schematic for clarity, yet retaining the 
true structure of the muscles) as shown in the 
lateral view (Fig. iv), sagittal (Fig. 11) and 
coronal sections (Fig. iii) illustrate that it is 
almost impossible to state exactly which muscle 
bundles are limited to the levator and which 
are limited to the deep external sphincter 
muscle. Therefore, it is only a matter of opin- 
ion whether the coccygeal muscular raphe is 
composed entirely of muscle bundles, limited to 
the inferior layer of the levator (in which case 
none of the fibers of the deep external sphincter 
would find attachment to the coccyx) or 
whether some of the fibers of the deep external 
sphincter also pass through the coccygeal 
muscular raphe posteriorly. From the stand- 
point of clarity and clinical application the 
dissections indicate that the first viewpoint 
appears more practical. However, it may be 
stated safely that the muscle bundles forming 
the puborectalis sling have two separate dis- 
tributions posterior to the anorectum; one 
group of muscle bundles passing posteriorly 
by way of the coccygeal muscular raphe to 
insert into the tip and sides of the coccyx and 
the other group of fibers splitting off and in- 
serting into the corium along the anococcygeal 
skin sulcus. The separation between these two 
groups of muscle fibers as they pass to their 



164. 


Courtney — Pelvic Diaphragm and Anorectal Musculature 



Fig. VII. Drawing of coronal section of dissected male pelvis, somewhat sche- 
m.atic, made through the middle of the anorcctum showing the definite anatomic 
pathways as they occur in anorectal infections and the usual manner in which 
abscesses break through from one perirectal space to anotlier, as shown by the 
arrows (dissection bj' the author) and the relationship of the lateral extensions of 
the posterior levator space, lateral to the rectum, i. Circular muscle layer of 
rectum. 2, Longitudinal muscle layer of rectum. 3, Levator fascia. 4, Superior 
layer of levator muscle. 5, Inferior layer of levator muscle. 6, Anal fascia. 7, Com- 
bined longitudinal muscle laj’er of rectum. 8, Deep external sphincter muscle of 
anus. 9, Anal intermuscular septum. 10, Subcutaneous external sphincter muscle of 
anus. II, Fat of ischio-anal fossa. 12, Lateral extension of posterior levator space. 

A, Abscess in pelvirectal space as a result of “break through” from lateral 
extension of the posterior levator space (uncommon). B, abscess in lateral exten- 
sion of posterior levator space (common), c, abscess in ischio-anal fossa as a 
result of “break through” from the lateral extension of the posterior levator 
space (rare), n, abscess in the ischio-anal fossa, with fistulous tract connecting 
the circumanal .space and passing outward between the subcutaneous and deep 
portions of the external anal sphincter muscle (verj’ common; superficial or peri- 
anal variety). E, abscess in the circumanal space formed around a lower branch 
of an anal duct, f, subcutaneous fistulous tract; point of origin in an anal crj’pt 
and duct (very common; superficial or perianal variety), g, fistulous tract 
originating in an anal crypt and duct, thence passing laterally along the circum- 
anal space to break through into one of the ascending tracts in the combined 
longitudinal muscle layer of the rectum to form an abscess in the pelvirectal 
space (common), h, abscess in the ischioanal fossa which originates as in “g” 

(very common; superficial or perianal variety), i, schematic representation of an 
anal duct penetrating the internal sphincter and the combined longitudinal 
muscle layer of the rectum. J, (anatomic pathway within the combined longi- 
tudinal muscle layer of the rectum connecting the pelvirectal and circumanal 
spaces (the level of the anal intermuscular septum), k, abscess in ischio-anal 
fossa as a result of “break through” from the pelvirectal space (very rare), l, 
abscess in pelvirectal space; origin in anal ciypt and duct as e.xplained in “g” 

(common), m, abscess of pelvirectal space which has ruptured through the entire 
bowel wall into the rectum, thereby forming a high secondarj' opening within the 
lumen of the rectum (uncommon), 

attachments forms the posterior subsphincteric stated that the e.xternal sphincter muscle arose 
space connecting the two ischio-anal fossae, from the cloacal sphincter and also that the 
(Figs, ii-ii, 1V-4 and v-arrow.)“ levator ani muscle arises in connection with 

It is questionable whether the subcutaneous the coccygeus muscle and gradually descends 
Sphincter is ectodermal in origin as suggested to the rectum, bladder, prostate and vagina 
by Thompson, a remnant of the cloacal sphinc- and thus comes into contact and intimate union 
ter described by Popowsky,'® or whether it takes with the muscles of this region (the external 

origin from the ischial tuberosities. Popowsky sphincter and the perineal muscles). 

American Journal of Surgery 


165 


Courtney — Pelvic Diaphragm and Anorectal Musculature 


Since the dissections indicate that the sub- 
cutaneous sphincter is apparently a separate 
muscle from the deep external sphincter, they 
also suggest that the subcutaneous portion of 
the external sphincter muscle was the muscle 
referred to by Popowsky; whereas, the deep 
portion of the external sphincter muscle is 
formed, at least in part, from the levator ani 
muscle. 

Reference to textbooks on embryology"’''*-*® 
merely quote Popowsky. Since very little has 
been written on the embryology of this region. 
It remains for the embryologists to clarify this 
point. 

Combined Longitudinal Muscle Layer of the 
Rectum. This phrase describes the thickened 
portion of the longitudinal muscle layer of the 
rectum which extends inferiorly from the level 
of the levator fascia to the perianal skin below. 
It is composed of the longitudinal muscle layer 
of the rectum, fibers from the levator fascia 
and muscle fibers from both the superior and 
inferior layers of all three portions of the leva- 
tor muscle (puborectalis, pubococcygeus and 
iliococcygeus). This combined layer com- 
pletely encircles the rectum below the level of 
the levator fascia. Inferiorly, it splits up into 
many thinner layers which separate and sur- 
round the individual muscle bundles of the 
external sphincter and terminate by inserting 
into the corium thus forming the so-called 
corrigator muscle of the anal skin. (Figs, ii-i, 5; 
111-5, 6; V, VI and V11-7.) The layers which sepa- 
rate the muscle bundles of the deep sphincter 
are filamentous while those separating the 
muscle bundles of the subcutaneous sphincter 
are fairly thick (Fig. in.) The combined layer 
also forms the sheath of the subcutaneous 
sphincter. The lateral layer of this sheath, 
separating the subcutaneous and deep external 
sphincter muscles, is exceptionally heavy. 
(Figs. 1V-7 and v.) Laterally, some of the fibers 
which pass between the various muscle bundles 
of the sphincter traverse the fat of the ischio- 
anal fossa before reaching their insertion into 
the corium. Medially, a dense band of the 
combined longitudinal muscle layer passes 
between the subcutaneous portion of the ex- 
ternal sphincter and the internal sphincter 
muscle (the thickened inferior portion of the 
circular muscle layer of the rectum) to become 
firmly attached to the skin of the anal canal. 
The attachment at this point forms what is 
known as the anal intermuscular septum, or in 

January, ig^o 


the surface view, the white line of Hilton. 
(Figs. 11-15, 111-8 and vii-p.) From this point 
this same band of muscle fibers swings around 
the internal sphincter muscle (lying between 
the internal sphincter and the modified skin 
of the anal canal to which it Is firmly attached) 
and passes upward to the anorectal line, finally, 
to become lost in the fascia surrounding the 
superior hemorrhoidal vessels at an indefinite 
level above the anorectal line. (Fig. 111-8.) It 
will be seen, then, that this combined layer 
of the longitudinal muscle forms a U-shaped 
sling around the lower edge of the internal 
sphincter muscle along which a blunt probe 
can be passed encircling the anus. Fistulous 
tracts originating from infections within the 
glands and crypts of Morgagni pass trans- 
versely around the anus within and along this 
U-shaped layer of muscle within the circum- 
anal space (Figs. 111-7 and vii-G) to open 
externally at some distant point (contiguity). 
This particular bundle of muscle fibers is 
densely attached to the modified skin of the 
anal canal between the anal intermuscular 
septum and the anorectal line. 

In 1896 Stroud^' gave the name of pecten to 
the modified skin of the anal canal and claimed 
that the deeper tissue (dermis) was composed 
chiefly of nerve elements. Some clinicians*' 
now speak of a pathologic condition which they 
call pectenosis in which the fibrous tissue 
underlying the pecten of Stroud becomes in- 
creased in thickness, supposedly due to anal 
infections. They offer no scientific proof for 
their assumptions. The dissections show that 
this so-called pectenosis is not an entity in 
itself and the tissue they describe consists of 
the attachments of the combined longitudinal 
muscle layer to the modified skin of the anal 
canal. It is a normal anatomic structure and 
varies in thickness in each individual just as 
the musculature of individuals vary. These 
findings are confirmed by Hiller'^ and Fine 
and Lawes® histologically. 

The combined longitudinal muscle layer has 
further prolongations of fairly strong fibrous 
sheets which run obliquely downward and in- 
ward between the individual muscle bundles 
of the internal sphincter. These layers are 
attached to the combined longitudinal muscle 
fibers which make up the U shaped sling around 
the internal sphincter previously described; for 
example, attached to the anal intermuscular 
septum at the bottom of the U and the ascend- 



i66 


Courtnej' — Pelvic Diaphragm and Anorectal Musculature 



Fig. vm. Line drawings of superior view of dissected m.ale pelvis 
(dissection by the author), i, a-a', muscle bundle from longi- 
tudinal muscle layer of rectum to form sphincter or urethra; 
b-b’, muscle bundle from longitudinal muscle layer of rectum, 
passing laterally, intermingling with fibers of the superior layer 
and also the main bundles of the levator muscle. 2, a-a', muscle 
bundle from superior layer of puborectalis muscle to help form 
iliorectococcygeus muscle; b-b', muscle bundle of iliococcygeus 
muscle, passing by way of its inferior layer to the coccygeal 
muscular raphe. 3, a-a', muscle bundle from longitudinal 
muscle layer of rectum to help form iliorectococcygeus muscle; 
b-b', muscle bundle from iliococcygeus passing by way of its 
superior layer to help form the iliorectococcygeus muscle; c-c', 
muscle bundle from longitudinal muscle layer of rectum to 
help form the lateral puboprostatic ligament. 

ing upright of the U as it passes upward to the der. This study shows that these fibers continue 

anorectal line medial to the internal sphincter into the tip of the prostate and surround the 

muscle. These layers gradually decrease in urethra to form the sphincter of the urethra, 

thickness and strength from below upward, and (Fig. viii-la-a'.) A review of the literature 

become filamentous by the time the upper level does not reveal a similar description, 
of the internal sphincter is reached. On each side of the recto-urethralis muscle 

Altachme7its 0/ the Longitudinal Muscle the longitudinal muscle layer of the rectum 

Layer of the Rectum to the Pelvis. As previously gives off fibers which unite with the most 

described®"® fibers'from the longitudinal muscle medial fibers of the puborectalis muscle and 

layer of the rectum help to form the 'iliorecto- the levator fascia to form two strong fibro- 

coccygeus muscle and through it are inserted or muscular, tendinous bands, the lateral pubo- 

attached to the bony pelvis (sacrum and prostatlc ligaments. (Fig. viii-sc-c'.) Many 

coccyx) posteriorly. (Fig. vni-3a-a'.) writers have stated that the lateral pubo- 

Anteriorly, the longitudinal muscle layer of prostatic ligaments contain smooth muscle 

the rectum gives off fibers formerly described fibers but a review of the literature reveals this 

as the recto-urethralis muscle. Earlier writers is apparently the first time that these smooth 

have described these fibers as inserting into muscle fibers have been demonstrated as being 

the fascia surrounding the prostate and blad- one of the terminations of the longitudinal 

American Journal of Surgery 



Courtney— Pelvic Diaphragm and Anorectal Musculature 167 



Fig. IX. Line drawings of mid-sagittal section of dissected male pelvis (dis- 
section by the author). 1, a-a', muscle bundle from inferior layer of puborectalis 
muscle passing by way of the sling of the puborectalis muscle and the deep 
external sphincter muscle to help form the bulbocavernosus muscle; b-b', this 
line indicates the depth in a vertical direction of the central tendinous point of 
the perineum which extends from the level of the raphe of the bulbocavernosus 
muscle inferiorly to the level of the rccto-urcthralis muscle superiorly. 2, a-a', 
muscle bundle from the inferior layer of the puborectalis muscle passing by 
way of the sling of the puborectalis and the coccygeal muscular raphe to 
attach to the coccyx; b-b', muscle bundle from the inferior layer of the pubo- 
rectalis muscle passing through the sling of the puborectalis and the deep 
external sphincter to decussate through the central tendinous point of the 
perineum and again decussating posterior to the anorectum to insert into 
the dermis along the anococcygeal raphe; (x) indicates schematically the 
central tendinous point of the perineum. 3, a-a', muscle bundle from deep layer 
of puborectalis passing by way of the sling of the puborectalis and the deep 
external sphincter through the central tendinous point of the perineum, 
whence it continues to either the transverse perineal muscle or to the anal 
fascia or across the ischio-anal fossa to insert into the dermis; b-b', muscle 
bundle from opposite side (left) puborectalis muscle decussating anteriorly 
through the central tendinous point of the perineum, thence passing by way of 
the deep external sphincter and the posterior subsphincteric space, across the 
ischioanal fossa to insert into the dermis. 


fibers of the bowel. Laterally, longitudinal 
muscle fibers of the rectum pass outward, inter- 
mingling with the fibers of the superior layer 
of the levator, and become lost among the 
muscle fibers of the main bundles of the 
levator, lateral to the point of division of the 
levator into its superior and inferior layers. 
(Fig. viii-ib-b'.) Even though these lateral 
fibers could not be traced to the various points 
of origin of the levator (as far as the arcuate 
line of the pubis, etc.), it is logical to assume 
that at one time they extended to the bony 
pelvis. Thus we find that fibers from the longi- 
tudinal muscle layer of the rectum are inserted 
into the pubis in front, the sacrum and coccyx 
behind and into the levator muscle laterally. 

January, ig$o 


Central Tendinous Point oj the Perineum. 
Previous descriptions and drawings of the 
central tendinous point of the perineum as they 
appear in our present textbooks and the litera- 
ture must have led others to believe, as it did 
myself, that this area or point was a rather 
thin, tendinous area located rather super- 
ficially anterior to the anus just beneath , the 
deep layer of the superficial fascia. It has been 
stated that many of the muscles of the peri- 
neum either take origin or insert into this point. 
This, however, is not the case. By blunt dissec- 
tion and scratching with a fine stiff probe it was 
found that many of the muscle fibers became 
fibrotendinous at this point, that they neither 
arise nor insert into this area but that they can 



68 


Courtney — Pelvic Diaphragm and Anorectal Musculature 



Fig. X. Line drawings of coronal section of dissected male pelvis (dissection by the 
author), i, Stippled area indicates schematically the sling of the puborectalis 
muscle. The fibers above the stippled area are passing posteriorly to form the 
coccygeal muscular raphe; those below it form the deep external sphincter muscle. 
2, a-a'-a", muscle bundle from sling of puborectalis passing by way of the deep 
sphincter muscle and the central tendinous point of the perineum to insert into the 
anal fascia at (a') or to pass on across the ischio-anal fossa to insert into the dermis 
at (a"); h-h', muscle bundle from sling of puborectalis to coccygeal muscular raphe; 
(.v) Indicates schematically central tendinous point of the perineum. 3, a-a', muscle 
bundle from sling of puborectalis passing by way of the deep external sphincter mus- 
cle and the central tendinous point of the perineum to the superficial transverse 
perineal muscle; (x) indicates schematically central tendinous point of the perineum. 


be traced directly through the central tendinous 
point of the perineum, often resuming their 
muscular configuration again to pass on to 
their various points of attachment. In other 
words, the fleshy bellies of these muscle fibers 
become fibrotendinous to resume their normal 
muscular configuration again after decussation. 
This is probably due to the action of body 
mechanics in the central tendinous point of the 
perineum as the fibers cross and rub against 
each other in this particular area. The dissec- 
tions show that in reality the central tendinous 
point of the perineum should not be considered 
as a thin, flattened-out point but consists of a 
decussating area of fibrotendinous and muscu- 
lar fibers of some considerable depth in a 
vertical direction. The inferior limit of this 
area is formed by the decussating fibers of the 
subcutaneous sphincter as they pass to the 
raphe of the bulbocavernosus muscle (in 
the male) and ends superiorly at the level of 


the recto-urethralis muscle. The muscle fib 
decussating inferiorly are often fibrotendinc 
while those crossing more superiorly reti 
their muscular structure. (Fig. ix-ib-b'.) 

Since the anorectal sphincter musculature 
comprised of both skeletal and visceral muscl 
it is not onlj"^ under the control of the cent 
nervous system but also the autonomic (syrnf 
thetic and parasympathetic) nervous syste 
Thus it is apparent that we must consider t 
muscles of the pelvic diaphragm, the interr 
and the external anal sphincter muscles as o 
unit from the standpoint of function. 

This study indicates that the anoreci 
sphincter musculature is divisible into ts 
separate portions: (i) The first portion is 
composite muscle group made up of (a) 
levator and deep external sphincter muscle 
(b) the combined longitudinal muscle lay 
of the rectum and (c) the internal sphinct 
muscle. The main function of this portion 

American Journal of Surge, 


169 


Courtney — Pelvic Diaphragm and Anorectal Musculature . 



FtG. XI. Line drawings of lateral view of dissected male pelvis (dissection by the 
author), i, a-a', muscle bundle from inferior layer of the puborectalis muscle 
decussating anteriorly through the central tendinous point of the perineum and 
encircling the anorectum by way of the deep sphincter and intermingling with 
the fibers of the bulbocavernosus muscle; b', muscle bundle from the sub- 
cutaneous sphincter muscle joining those of the bulbocavernosus muscle; (x) 
indicates schematically the central tendinous point of the perineum. 2, a', 
muscle bundle from the deep external sphincter muscle inserting into the 
dermis along the anococcygeal skin sulcus; b', muscle bundle from the deep 
ex-temal sphincter muscle inserting into the dermis along the anal-scrotal 
raphe; c', muscle bundle from the subcutaneous sphincter muscle inserting 
same as 6'; d', muscle bundle from the deep external sphincter muscle decus- 
sating through the central tendinous point of the perineum and passing by way 
of the superficial transverse perineal muscle to attach to the ischial tuberosity; 
(x) indicates schematically central tendinous point of the perineum. 3, a-a', 
indicates muscle bundles from the pubococcygeus and b-b' the iliococcygeus 
muscles, respectively, which pass into the deep external sphincter muscle 
laterally; c', muscle bundle from the subcutaneous sphincter muscle inserting 
into the dermis along the anococcygeal skin sulcus; (x) indicates central 
tendinous point of the perineum. 


sphincter control. (2) The second portion 
comprises the subcutaneous sphincter muscle. 
Apparently its function is to cut off the stool 
and close the anus tightly. Clinically, the sub- 
cutaneous and internal sphincter muscles are 
unimportant from the standpoint of sphincter 
control; either may be severed separately or 
at the same time without any appreciable loss 
of sphincter control. 

SURGICAL CONSIDERATIONS 

Gray’s anatomyio under “myology” states: 

In the description of a muscle, the term origin 
is meant to imply its more fixed or central 
attachment; and the term insertion the mov- 
able point on which the force of the muscle is 
applied; but the origin is absolutely fixed in 
only a small number of muscles, such as those 
of the face whieh are attached by one ex- 

January, 1950 


tremity to immovable bones, and by the other 
to the movable integument; in the greater 
number, the muscle can be made to act from 
either extremity.” 

As revealed by this study the points of in- 
sertion or attachment upon which the force of 
the muscle is applied are as follows: posteriorly, 
(i) the attachment of the iliorectococcygeus 
muscle to the coccyx and sacrum, (2) the at- 
tachment of the coccygeal muscular raphe to 
the tip and sides of the coccyx (the most im- 
portant anchoring support posteriorly) and 
(3) the attachment of the deep and subcu- 
taneous external sphincter muscles to the 
dermis along the anococcygeal skin sulcus; 
anteriorly, (i) the central tendinous point of 
the perineum and (2) the attachment to the 
subcutaneous and deep external sphincter 



. Courtney — Pelvic Diaphragm and Anorectal Musculature 



Fig. XII. Drawing showing the location and extent of the various incisions used for exploration and 
counter-drainage of deep peri-ano-rectal abscesses and fistulas; these incisions are devised on an 
anatomic basis to preserve the attachments of the anorectal sphincter musculature. The patient is 
lying in the inverted or jack-knife position. 

Fig. xui. Drawing showing the second step of the actual operation (made somewhat schematically 
in that an excess amount of fat has been removed from eaeh ischio-anal fossa) to show the relation- 
ships of the deep external anal sphincter muscle and those of the lateral extensions of the posterior 
levator space lying between the inferior and superior layer of the levator muscle. On the patient’s 
left the inferior layer of the levator has been divided and the lateral portion of this muscle has 
been pulled upward and outward with a hook exposing the lateral extension of the posterior 
levator space. On the patient’s right the superior layer of the levator has been incised, thereby 
laying open the pelvirectal space. The patient is lying in the inverted or jack-knife position. 

Fig. xiv. Drawing showing the third step of the actual operation (made somewhat schematically 
in that an excess amount of fat has been removed from each ischio-anal fossa) to show the relation- 
ships of the deep external anal sphincter muscle, the levator muscle and the superficial transverse 
perineal muscle (shown in the anterior portion of the uncapped abscess wound on the patient’s 
right side). The method of passing the drains from the primary posterior exploratory incision 
through the abscess cavities in the posterior levator, retrorectal and pelvirectal spaces and out 
through the lateral counter-drainage incisions is illustrated. The drains should be fastened external 
to the wounds. The patient is lying in the inverted or jack-knife position. 

Fig. XV. Drawing showing the use of a posterior horseshoe incision (made somewhat schematically 
in that an excess amount of fat has been removed from each ischio-anal fossa). This type of incision 
should be reserved for that very small group of cases by xvhich it is the only means possible in 
chronic fistulas to secure adequate exposure for the excision of the fistulous tract and the cleaning 
out of an old abscess cavity remaining in the posterior levator or retrorectal spaces. The transverse 
part of the ineision should be made well back toward the tip of the coccyx, and the skin with the 
insertions of the deep external sphincter muscle into it should be reflected anteriorly as shown. 

This incision is carried superiorly to the bottom of the posterior subsphincteric space (that is to the 
inferior surface of the coccygeal muscular raphe). By preserving the attachments of the deep 
external anal sphincter muscle into the skin a higher degree of sphincter control can be maintained 

American Journal oj Surgery 


Courtney — Pelvic Diaphragm and Anorectal Musculature 171 


muscles to (a) the dermis along the anal scortal 
raphe, (b) to the raphe of the bulbocavernosus 
muscle and (c) to the bulbocavernosus muscle 
itself; laterally, the attachments of the super- 
ficial transverse perineal muscles to the ischial 
tuberosities on either side. Sphincter control is 
dependent upon the preservation of these 
various points of attachment or insertion of the 
anorectal sphincter musculature. 

For many years the literature has carried 
warnings concerning the marked loss in 
sphincter control resulting from deep division 
of the anorectal sphincter musculature an- 
teriorly and anterolaterally, not merely the 
subcutaneous portion of the external sphincter 
muscle. Little has been said concerning the 
division of the musculature posteriorly which 
occurs from the use of the posterior horseshoe 
incision. However, it has been mentioned that 
severe deformity often results and that the 
anus becomes displaced anteriorly and inward, 
with marked loss of sphincter control. 

As a result of this study surgical incisions 
for use in anorectal fistula surgery have been 
devised on an anatomic basis to preserve the 
attachments of these muscles. The use of these 
various incisions has given most satisfactory 
cosmetic and functional results. (Fig. xii.) 

Subcutaneous para-anal abscesses and fistu- 
las present no problem since division of the 
subcutaneous portion of the external sphincter 
muscle alone is required. 

Deep posterior abscesses involving the 
posterior levator and retrorectal spaces should 
be opened and explored through a posterior 
midline incision extending posteriorly from 
the anorectal wall to the tip of the coccyx. This 
incision separates rather than severs the fibers 
of the external sphincter muscle, the coccygeal 
muscular raphe and the iliorectococcygeus 
muscle, respectively. (Fig. xii.) It also places 
the anal end of the incision in close proximity 
to the usual posterior location of the primary 
opening. 

It is advisable to open all deep abscesses 
under direct vision, laj'-er by layer, to be 
absolutely certain of landmarks. 


Lateral abscesses and fistulas involving (i) 
the ischio-anal fossae, especially the posterior 
horseshoe variety, (2) the lateral extensions of 
the posterior levator space and (3) the lateral 
pelvirectal spaces should be uncapped or 
counterdrained by curvilinear incisions parallel- 
ing the external sphincter muscle.® The pos- 
terior ends of these lateral incisions should be 
terminated at the lateral margins of the 
posterior insertions of the external sphincter 
muscles into the skin, and/or at the lateral 
margins of the coccygeal muscular raphe, 
and/or the iliorectococcygeus muscle, re- 
spectively. (Fig. XII.) 

In posterior horseshoe abscess (ischio-anal) 
it is merely necessary to pass a Penrose drain, 
from one incision to the other, through the 
posterior subsphincteric space.^ In chronic 
fistulas it is necessary to excise or destroy by 
curettage that portion of the tract passing 
through the posterior subsphincteric space 
before inserting the drain. 

In abscesses and fistulas involving one or 
both lateral extensions of the posterior levator 
space and in those complicated cases in which 
an abscess of the retrorectal space has broken 
through the rectal stalks into the pelvirectal 
spaces, the same technic is followed with 
reference to placing the drain beneath or 
around the coccygeal muscular raphe or the 
Iliorectococcygeus muscle, respectively, as the 
case may be.® (Fig. xiv.) 

In deep lateral abscesses e.xtending beneath 
the superficial transverse perineal muscle it is 
usually unnecessary to sever this muscle. The 
abscess cavity or fistula should be extensiveljr 
uncapped, both anterior and posterior to the 
muscle, and one or more Penrose drains in- 
serted around the muscle in a U-shaped manner 
and fastened external to the wounds. (Fig. xiv.) 

Bilateral anterior abscesses and fistulas 
which communicate with each other across the 
midline (by way of the central tendinous point 
of the perineum) should be uncapped and 
drained in the same manner as those occurring 
posteriorly. Each anterolateral incision should 
be terminated medially at the lateral margins 


than when the muscle is divided close to the anu.s. The coccygeal muscular raphe is shown in the 
drawing as the white fibrotcndinous area extending from the reflected skin flap posteriorly to the 
tip of the coccyx. The manner by which its fibers arc separated rather than severed by the primary 
posterior midline exploratory incision (Fig. xii) is shown. The surgeon must use his own discretion 
as to the manner in which he handles the coccygeal muscular raphe. If this structure is completely 
severed transversely, the mam anchoring support of the anorectum posteriorly is destroyed- the 

anus will become displaced forward and inward with marked deformity and a severe loss of 
sphincter control will usually result. severe loss oi 


January, ig^o 



172 


Courtney — Pelvic Diaphragm and Anorectal Musculature 


of the anterior musculature. A Penrose drain 
should be inserted beneath the muscles, passing 
from one incision to the other and fastened 
external to the wounds. (Fig. xii.) 

In the perineal phase of a pull-through 
operation for resection of the bowel with 
preservation of the anal sphincter muscles, a 
much higher percentage of sphincter control 
can be maintained by making use of the 
posterior levator space in separating the bowel 
from its surrounding musculature posteriorly 
and laterally than by dividing the entire thick- 
ness of the levator ani as described by some 
authors. In performing this phase of the opera- 
tion the posterior levator space is most easily 
entered posteriorly or posterolaterally by 
cutting through the wall of the bowel from 
within its lumen. After passing through the 
mucosa, submucosa, internal sphincter and 
combined longitudinal muscular layer of the 
rectum the circular muscle fibers of the deep 
external sphincter muscle will be recognized. 
Employing the combined longitudinal muscle 
fibers as a guide medially and the circular 
muscle fibers of the deep external sphincter 
muscle laterally, the separation is continued 
cephalad until the posterior levator space is 
entered. Sharp dissection is necessary up to 
this point to sever the fibers of the combined 
longitudinal muscle layer of the rectum which 
pass laterally between the muscle bundles of 
the deep external sphincter muscle. From this 
point on the loose aerolar tissue of the posterior 
levator space is easily separated with the knife 
handle or the gauze- covered finger until the 
iliorectococcygeus muscle (thin superior layer 
of the levator ani muscle) is reached. This 
separation is easily and quickly performed and 
practically no bleeding is encountered. The 
division of the superior layer of the levator has 
little effect on sphincter control. By following 
this natural plane of cleavage the function of 
the anorectal sphincter musculature is pre- 
served almost in its entirety. 

This investigation has changed our concept 
concerning the manner in which the anorectal 
sphincter mechanism functions and emphasizes 
the important part the levator ani muscle plays 
in its operation. Therefore, those surgeons who 
divide the levator widely (lateral to the point of 
subdivision into a superior and inferior layer) 
are destroying praetically two-thirds of the 
origin of this muscle. Such a division destroys 
the origin of the entire iliococcygeus muscle, a 


portion of the pubococcygeus muscle and, also, 
some of the important muscle bundles which 
either pass into the deep external sphincter an- 
terolaterally or those which decussate through 
the central tendinous point of the perineum. 
Thus those portions of the muscle which have 
been cut off from their fixed origins are obliged 
to function against the points of their insertion. 
This results in a much lower degree of muscle 
contraction or efficiency than when the main 
portions of the muscle are preserved. 

SUMMARY 

1. The anatomy of the anorectal sphincter 
musculature is described in detail. 

2. The various components of this muscu- 
lature important to sphincter control are 
enumerated. 

3. Methods for preserving these important 
structures in fistula surgery and bowel resection 
are described. 

4. Surgical incisions (devised on an anatomic 
basis) which have proved useful from the stand- 
point of sphincter preservation are suggested. 

REFERENCES 

1. Abel, A. La whence. The pecten band, pectcnosis 

and pcctenotomy. Lancet, i: 714, 1932. 

2. Blaisdeul, Paul C. Operative injurj' to the anal 

sphincter. J. A. M. A., 112: 614, 1939. 

3. Courtney, Harold. Anatomy of the anorectal and 

perianorectal areas (as related to the spread of 
infection by contiguity). Thesis. Unxv. Pennsyl- 
fania, 1940. 

4. CouRT.NEV, Harold. The posterior levator space 

(its relation to postanal infection). Tr. Am. Proct. 
Soc., 45: 450-455, 1946. 

5. Courtney, Harold. Posterior levator space 

abscess. Am. J. Surg., 75: 405-412, 1948. 

6. Courtney, Harold. Abscesses of the deep peri- 

rectal spaces their significance, diagnosis and 
treatment. Neia York State J. Med., 47: 2552- 
2559, 1947- 

7. Courtney, Harold. The posterior subsphincteric 

space — its relation to posterior horseshoe fistula. 
Surg., Gynec. & Obst. 89: 222-226, 1949. 

8. Fine, J. and Lawes, C. H. Wickham. On the 

muscle-fibres of the anal submucosa, with special 
reference to the pecten band, Brit. J. Surg., 27: 
723-727, 1940. 

9. Gorsch, R. V. Perineopelvic Anatomy, pp. 60-137 

and pp. 179-208. New York City, 1941. The 
Tilghman Co. 

10. Lewis, Warren, H. Gray’s Anatomy, ed. 20, pp. 

361-378. Philadelphia, 1918. Lea & Febiger. 

11. Hamilton, W. J., Boyd,- J. D. and Mossman, 

H. W. Human Embryology, p. 312. Baltimore, 
1945. Williams & Wilkins Co. 

12. Hiller, Robert I. Anal anatomy with reference 

to the white line of Hilton and the pecten of 
Stroud. Ann. Surg., 102: 81, i935' 

American Journal of Surgery 



173 


Courtney — Pelvic Diaphragm and Anorectal Musculature 


13. Holl, M. Die Muskeln unci Fascien des Becken- 

ausganges, Von Bardelben, Handbuch der 
Anatomic des Menschen, Band 7, Teil 2, Ab- 
teilung 2. Jena, 1897. 

14. Keibel, Franz and Mall, Franklin P. Manual of 

Human Embryology Vol. i, pp. 478-480. Phila- 
delphia, 1910. J. B. Lippincott. 

15. Levy, Edward. Anorectal musculature. Am. J. 

Surg., 34: 141-198, 1936. 

16. Miles, W. Ernest. Observations upon internal 

piles. Surg., Gynec. & Obst., 19; 497, 1919. 

17. Milligan, E. T. C. and Morgan, C. Naunton. 

Surgical anatomy of the anal canal. Lancet, 2: 
1150, 1934. 

18. Patten, B. M. Human Embryology, p. 306. 

Philadelphia, 1947. The Blakiston Co. 

19. PopowsKY, J. Zur Entwickelungsgeschichte dcr 

Dammuskulatur beim Menschen. Anal. Hejte, 
12: 15-48, 1899. 

20. Spiesman, Manuel G. Essentials of Clinical Proc- 

tology, pp. 54-62. New York, 1946. Grune & 
Stratton. 

21. Stroud, Bert B. On the anatomy of the anus. 

Ann. Surg., 24; i, 1896. 

22. Thompson, Peter. The Pelvic Diaphragm, Studies 

in Anatomy. From the Anatomical Department 
of Owens College, Manchester. Vol. 2, p. 139. 
J. E. Cornish, 1900. 

DISCUSSION OF PAPERS BY DRS. MORGAN AND 
COURTNEY 

W. B. Gabriel (London, England): I am sure 
we all appreciate the importance of a sound 
anatomic knowledge in this region. I would like to 
urge the younger members of this Society to get 
down to these points of anatomy. Milligan and 
Morgan’s classical paper appeared in 1934 so that 
we have had quite a number of years to get used to 
the conception of the external sphincter which was 
put forward. Then Mr. E. T. C. Milligan’s paper 
on the perianal and perirectal spaces appeared, I 
think, in 1943 when he gave us the anatomic 
boundaries and contents of the perianal space, the 
submucous space and so on. 

Then there was Mr. C. Naunton Morgan’s recent 
Presidential Address to the Section of Proctology 
of the Royal Society of Medicine (November, 
1948), which I am bound to say I found somewhat 
difficult in places. But I think this sort of thing 
grows on one and I found his presentation today 
more comprehensible than on the first occasion. I 
am sure if you will get down to it it will grow on 
you and you will gradually see daylight by studying 
these diagrams and discussing it among yourselves. 


I should like to thank Mr. Morgan and Dr. 
Courtney for their papers. As a surgeon, when I get 
a patient with a large postrectal abscess I always 
judge it to be below the levator. I drain it and then 
deal with the lateral extensions. My belief is that 
these deep postrectal abscesses, as I call them, are 
quite definitely below the levator. 

Rudolph V. Gorsch (New York, N. Y.): I 
scarcely need mention that I am highly apprecia- 
tive of the honor and privilege of having this op- 
portunity to discuss this excellent presentation of 
surgical anatomy by my esteemed friend and 
colleague, Mr, Morgan. 

We proctologists here in America are keenly 
aware of the fundamental and practical contribu- 
tions made by our British confreres, particularly 
the long and distinguished group from St. Mark’s 
Hospital in London. 

The stimulus and constructive influence which 
they have had on our proctologic activities is too 
well known to all of you to require further comment 
from me. 

I also want to commend Dr. Courtney on his 
tedious and critical anatomic investigations. 

Mr. Morgan has again emphasized the surgical 
importance of anorectal anatomy to which I can 
add but little. 

C. N. Morgan (closing): It has done my heart 
good to see the enthusiasm of both Dr, Courtney 
and Dr. Gorsch in putting it across. 1 think one 
of them has a very good practical knowledge of this 
area and 1 agree with my friend and colleague, Mr. 
Gabriel, that by now we would have found whether 
these abscesses were above or below or in the 
levator muscle — but they are below! 

Harold Courtney (closing): It was indeed a 
great honor and privilege to appear on this program 
with such distinguished surgeons as Mr. Morgan, 
Mr. Gabriel and our other guests from overseas. 

I was very glad to hear Mr. Gabriel state that he 
found the understanding of the anatomy of this 
particular region somewhat difficult in places. It is 
my personal opinion that the detailed anatomy of 
this region is without doubt one of the most difficult 
of any part of the human body to dissect and under- 
stand. I certainly agree with Mr. Gabriel that it is 
only by getting down to it and studying the text 
and illustrations and discussing the anatomy 
among yourselves that the whole matter will be 
clarified. 




January, 1950 



PLASTIC REPAIR OF THE INCONTINENT SPHINCTER ANP 


Paul C. Blaisdell, m.d. 
Pasadena, California 


I N previous articles we have discussed at 
length both the background and specific 
details of the surgical repair of the in- 
continent sphincter ani. Attention was directed 
to some aspects of the anatomic and phj'sio- 
logic vulnerability of the sphincter ani muscle 
in relation to surgical and obstetric injury of 
reasonably necessary degree and, on the other 
hand, of unjustified degree.’’-'® Statistical 
analysis was made of a series of cases tracing 
the exact origins of injury, appraising the 
factors of responsibility and incompetence and 
reporting in the aggregate the rather discour- 
aging results of orthodox repair.’’ Finally, 
several improvements in the surgical technic of 
repair were described.^’® While this article is a 
complete statement in itself, it is also a planned 
part of a more inclusive exposition. 

INDEPENDENT ROLE OF AN.\L DEFORMITY 

Heretofore, anal incontinence has been con- 
sidered both from the standpoint of function 
and repair exclusively in terms of muscle in- 
competence. At times this is true or at least 
near enough the truth for practical purposes. 
More commonly the variance is of serious 
Import to the patient; for in addition to the 
variable of muscle inefficacy, there is also the 
independent factor of anal deformity which can 
be responsible of itself for clinical incontinence 
independent of demonstrable sphincter impair- 
ment. Or when conjoined with muscle impair- 
ment the degree of incontinence is out of all 
proportion to the actual physiologic incom- 
petence of the muscle. 

Symptoms of incontinence are attributable 
to two distinct etiologic mechanisms or variable 
combinations thereof. (Digressing for a moment 
it is well to reiterate here what we have em- 
phasised on previous occasions that it may 
take very little deviation from normal to 
produce untoward symptoms out of seeming 
proportion to objective evidence of injury. As 
a matter of fact, there are many victims of 
minor though embarrassing degrees of in- 
continence — evidenced only by inability to 


control gas or by soiling — whose diagnosis is 
never entered on a chart. It is not uncommon 
with fissurectomies, for example, with too deep 
incision of the sphincter. The surgeon fails to 
inquire about the matter and the patient does 
not complain because he assumes the weakness 
to be an unavoidable residue.) 

Perhaps the more obvious of the two etiologic 
mechanisms of incontinence is by way of uni- 
form dilatation of the whole circumference of 
the anal musculature. It may be the fault 
of the surgeon through excessive stretching of 
the sphincter at operation, an evil which the 
competent proctologist bears constantly in 
mind. It may likewise follow the removal of 
large hemorrhoids which by constant prolapse 
over the years have gradually stretched the 
muscle. In the latter instances the muscle fails 
to contract to its original size and thus to 
accommodate for the spaces vacated by the 
hemorrhoids. 

On the other hand, severance of the anal 
sphincter of certain degree for a given quadrant 
or locus,’ may also increase the circumference 
to the point of residual malfunction but due 
entirelj’’ to local retraction and separation of 
ends. If the gap between these separated ends 
were filled in with tissue, any kind of tissue, it 
would make little difference as to whether 
dilatation or incision produced the increased 
circumference. Such is not the case, however, 
for with severance there is always left this 
definite residual hiatus which of itself and 
independent of increased circumference allows 
uncontrolled escape of bowel contents. Tj-pi- 
cally this hiatus is a channel or sort of valley 
which after bisecting fibers of the sphincter 
gradually joins the anal canal at an acute 
angle. On inspection this channel is con- 
spicuously and constantly patulous even though 
the remaining circumference of the anal canal 
itself remains visibly closed. On closer inspec- 
tion persistent fecal soiling of the scar-lined 
pocket is significant evidence of the inde- 
pendent and often predominant role of tire 
deformity in the uncontrolled leakage. Further 


From the Department of Proctology, College of Medical Evangelists, Los Angeles, Calif. 

174 American Journal of Surgery 



Blaisdell — Incontinent Sphincter Ani 


175 



Fig.' 1. Classic operation for repair of incontinent sphincter ani rnuscle. The inade- 
quacies and indifferent results are mentioned in the text and were previously described 
in detail.-' 


substantiating evidence that the hiatus is an 
additional factor to the result of simple dilata- 
tion can be found in the prolapse of the mucous . 
membrane solely down the channel of deformity 
and nowhere else around the circumference. At 
first this is demonstrable only at the upper end 
and through an anoscope. Later a glistening 
spot of prolapsing mucous membrane is visible 
approaching the outer end of the anus down 
the channel. In the light of this analysis the 
ideal surgical approach for reestablishment of 
continence should have the objective not only 
of restoring the original circumference of the 
sphincter but also of obliterating the pocket 
defect, and not either as a possible incidental 
effect but as a planned objective of equal or 
greater importance. This distinction from a 
practical and surgical standpoint makes con- 
siderable difference; for while it is true that 
repair of the sphincter muscle envisions con- 
comittant obliteration of the defect, it is solelj’’ 
by use of muscle tissue. Our concept, on the 
other hand, seeks use of any tissue available 
for obliteration of the cavity as a planned 

January, ig^o 



Fig. 2. Intravaginai reefing operation near eomple- 
tion; this has proven satisfactory in a limited field.-' 


Blaisdell — Incontinent Sphincter Ani 


176 



Fig. 3. Two-stage transplantation of muscIc-bcaring 
flaps designed for large defects; lines of incision for 
first stage are shown. A tongue-shaped flap of muscle- 
bearing tissue on each side with the tip at a is trans- 
planted and fixed at a. 

objective and in addition to muscle repair. This 
also permits overcorrection, an important 
adjunct to a favorable end result. 

In the past orthodox repair has assumed and 
must assume complete regression to the original 
status by well nigh perfect union of the care- 
fully dissected bare muscle ends (Fig. i) if 
both mechanisms of incontinence as sources 
of symptoms are to be counteracted. On this 
premise if successfully carried out, any analysis 
such as ours would obviously be only academic. 
Unfortunately, it is not as simple as it sounds 
and it has proven far more difficult to repair 
the muscle than to injure it, while overcorrec- 
tion sufficient to insure ultimate complete 
obliteration of the deformity has been out of 
the question. The indifferent results compiled 
from the records of a large number of proc- 
tologists^ cannot but bear out the innate 
obstaeles to this operation as a reliable and 
dependable procedure even in the hands of 
expert surgeons. It has proven to be contingent 
on a fortuitous combination of invariably 
favorable eircumstances and termination, wdth 
little leeway for shortcoming in any. Dissecting 
out the frayed ends of muscle embedded in 
scar tissue is apt to prove tedious and exacting 
and the excessive trauma is not compatible 
with precise plastic surgery, the more so in 
view of the high potentialities of infection so 
near to the anus. Sutures must engage sub- 
stantial bites of full-bellied muscle tissue which 
means dissection well past the area of frayed 
out ends even to admit end-to-end apposition 
to say nothing of overlapping for overcorrec- 
tion. Thus the surgeon can be insidiously if not 



Fig. 4. Two-stage transplantation (continued); wire 
sutures are shown being placed. We would now insist 
on mattress sutures tied over small buttons for any 
anal plastic surgery. 

rather necessarily lured into excessive sacrifice 
of tissue, which, with better planning, could 
otherwise be used for filling in and correcting 
the deformity. As a result the surgeon is apt to 
tveicome the close of his task only to find a 
suture line under excessive tension and sud- 
denly to face the realization which he had 
perhaps not broached to the patient that the 
latter might not only be unimproved bj'’ sur- 
gery but might even be worse. 

Early in our quest for improvement we layed 
down two a priori and absolute requisites and 
discarded without further consideration all that 
failed to so qualify. First, the operation must 
be simple; secondly, if it should fail in instances, 
it must not allow of making the patient anj'^ 
w'orse. Simplicity was regarded not only as a 
generally desirable virtue in itself but essential 
here for various reasons. Not the least impor- 
tant reason was that comparatively few sur- 
geons have anything like extensive experience 
with such cases and dissections. We could not 
under any circumstances reconcile tedious 
dissection in the potentially infected region of 
the anus with our eoncept of the best in plastic 
surgery and certainly we did not feel equal to 
facing a patient made worse by the ordeal. 

A first suggestion was that of an intravaglnal 
approach by way of a surgically cleaner field 
through normal unscarred tissue and to a 
normal segment of muscle. (Fig. 2.) In addition 
the apposition of the broader surfaces of a tuck 

American Journal 0/ Surgery 



Blaisdell — Incontinent Sphincter Ani 


177 



Fig. 5. Second stage of operation shown in Figures 3 and 4; in our original de- 
scription- this was suggested as a complete operation in itself for minor defects. 
Here, too, we would now substitute wire mattress sutures tied over buttons. 
Note that only half of extraneous tissue available bulges into the defect. With 
our inversion operation described in the text and illustrated in Figures 6, 7 and 8 
this amount of tissue is doubled for desirable overcorrection. 


as compared to apposition of dissected ends 
contravenes by the sheer take up any necessity 
for separate and special attention to the deform- 
ity. The latter tends to be obliterated by the 
forces and mechanism involved. Unfortunately, 
however, this operation is not universal in appli- 
cation; it is obviously useless in the male and 
comparatively so in cases of anterior injury while 
the[experience required is perhaps disproportion- 
ate to the incidence of use. 

MUSCLE-BEARING FLAP 

Further thought toward a more compre- 
hensive pattern led to the use of the muscle- 
bearing flap,® and the perspective afforded by 
time and trial has lent conviction that this will 
prove a basic concept in the management of 
anal incontinence. Theretofore it had appar- 
ently always been assumed necessary to dissect 
out and denude the muscle ends for suturing. 
While it is possible to surmise a number of 
reasons for this assumption such as its clear 
necessity in most locations of the body, they 
were unconvincing as applied here and e.\peri- 
ence in another direction has vindicated our 
skepticism. The muscle-bearing flap was first 
described by us in connection with one of the 
more severe and unusual examples of musele 
injury necessitating a two-stage sliding graft 
(Figs. 3, 4 and 5) but it is more broadly con- 
ceived as a basic element which can be adopted 
to different plans and varying situations. As 
described it incorporated a segment of sphineter 
muscle which itself was not disseeted out but 
which effectively lent its function to a properly 
shaped flap. 

January, ig^o 



Fig. 6. Inversion operation, a, first incision is shown 
and freeing of skin over scar. Preservation of this 
flap prevents a fistulous wound; it is important for the 
same reason not even to button-hole it. This first in- 
cision should be placed so as to have relationship 
shown with secondary incisions, a, the whole thickness 
of external sphincter is grasped in Allis forceps at 
both A and a in turn and peripheral circular incisions 
made to join original incision. Dissection of these is 
carried as deeply as possible without hazarding the 
slightest perforation which here, also, would prove 
disastrous. 


The second stage of this muscle-bearing flap 
operation consisted of a semi-lunar incision 
concentric with the anus across the remaining 
gap, the ends of the incision then being apposed 
by steel suture. It was determined at that time 
that this pattern tended to obliterate the hiatus 
by the inversion of extraneous non-muscle 
tissue as can be seen in Figure 5 which 
accompanied our article. Indeed, it would 
still be recommended (with the substitu- 



178 


Blaisdell — Incontinent Sphincter Ani 


tion of mattress sutures tied over buttons) 
except that ^ve have since evolved an even 
better method of obliterating the pocket while 
still retaining the principle of the muscle- 
bearing flap. 

The present design then is an adaptation of 
the principles just mentioned to the more com- 
mon problems of repair. Additionally, it not 
only obviates and simplifies much in the 
preparation of the heterogeneous flap but 
provides the maximum in obliterating the 
scar-lined hiatus of anything we have been able 
to devise. The muscle-bearing (lap is sufficiently 
freed only by deep, sharp dissection concen- 
trically and peripherally along the outer border 
to permit of independent role. Care is taken 
against penetration of the scar flap or of the 
mucosa or against other dissection which might 
cause a fistulous wound necessitating, for cure 
later, reseverance of the muscle and undoing 
of all accomplished by the attempted repair. 
One who does not understand these implica- 
tions should take heed. 

There is one other pertinent concept which, 
although no doubt understood and/or em- 
ployed by design or not, has escaped discussion. 
It is best described by the term “setting of the 
wound” and is perhaps most familiarly ex- 
emplified in the case of an open pilonidal 
wound.® Everyone is familiar with the resiliency 
of the latter at the time of operation and the 
ease with which the whole wound margins can 
be moved and slid, whereas later during the 
course of healing the wound becomes as though 
frozen and any changes of relationship are 
possible only by actual cutting. It is feasible 
and, indeed, often necessary to make definite 
use of this setting of the wound in plastic 
surgery of the anus. In a region where primary 
healing is the exception, firm and undisturbed 
setting of the wound over a sufficient period can 
compensate in remarkable measure. For this 
reason we make provision by means of wire 
suture tied over small buttons for protracted 
and effective retention. To the same end and 
as later described unusual provision is made for 
bowel eliminations. 

We now A^'ish to describe the rv'ider use and 
application of muscle-bearing, flaps in allevia- 
tion of the common type of relatively minor 
anal injury with incontinence. Presented here- 
with is^ an operation of marked simplicity and 
which in other respects, also, fulfills the criteria 
herein imposed. It has the following advantages 
over the usual repair: it is very much simpler, 
easier and quicker. The deformity is not only 


readily filled in but overcorrection is also 
achieved by the most advantageous use of the 
maximum available tissue. This overcorrection 
is important as it alone offsets the inevitable 
yielding of tissue during the extended healing 
period and is accomplished here chiefly b^' the 
use of tissue other than muscle. This useful 
tissue is sacrificed as e.xtrancous by the dis- 
section of the classical operation while only 
half of this available tissue is thus utilized in 
our previous plan represented in Figure 5. In 
the old operation tension on the suture line is 
an almost totally uncontrollable factor. In 
direct ratio to a pre-ordained bridging of space. 
With our operation there is no such pre- 
determined and necessary minimum and even 
division into stage operations is possible. Most 
important, tension is a controllable variable 
even after suture. Furthermore, the apposition 
of tissue is over much broader surfaces than 
afforded by mere touching of muscle ends. For 
all these reasons our operation offers ‘better 
prospect of effective wound healing. Finally, 
if the worst befell postoperatively, it is hard to 
postulate how a patient could be any worse 
off for the attempt which is not the case with 
dissection of the muscle ends. 

TECHNIC OF THE INVERSION OPER.\TION 

An incision is made through the skin de- 
lineating the outer edge of the pocket defect 
and the surface tissue covering the latter is 
carefully dissected free. (Fig. 6.) Of inestimable 
value for this is a Jones tonsil knife specially 
honed and stropped to bring the curved end as 
well as the sides to razor sharpness. Preserva- 
tion of this tissue intact is important for even 
minute buttonholing may transform the oper- 
ative dissection into a fistulous wound. 

The full body of the sphincter is seized 
within the bite of an Allis forceps, the teeth 
paralleling the fibers and placed exactly at 
the periphery (Fig. 6b) a little above the first 
incision. A second incision is made close to the 
Allis forceps along the periphery of the sphinc- 
ter, freeing a flap containing one end of the 
muscle and joining the original incision. The 
cut should go as deeply as possible without 
penetration of the intra-anal surface of the flap 
which would be disastrous. A third incision in 
similar manner frees a muscle-bearing flap on 
the other side of the defect. 

The two flaps are then united by a mattress 
suture with the peripherally freshened surfaces 
in apposition. (Fig. 7.) The two^ ends of the 
muscle and other intervening tissue are in- 

American Journal oj Surgery 



Blaisdell — Incontinent Sphincter Ani 


179 




D. 



'END 0 

Ifirst; 

•WIRE SUTURE 






Fig. 7. Placing of first steel wire stitch over buttons and diagram of result achieved. We have found this stitch 
to be more readily tightened to position and more effective if anchored at x as shown by dotted line; otherwise 
it tends to slip over the side in the direction of the arrow. If this stitch is correctly placed, the buttons should 
disappear into the anus. 

Fig. 8. Second steel suture placed, too tightly as shown here. Often one or more additional will be found advan- 
tageous. No attempt is made to approximate skin edges; indeed, this is averted purposely to prevent an abscess. 
A little packing is placed in the wound to expedite its setting. It is our present advice that the wound be care- 
fully examined in five days with the patient under anesthesia in lithotomy position. Ineffective or constricting 
sutures are then adjusted or replaced. 


vaginated toward the center of the anus to fill 
the defect. Progressive trial sutures of ab- 
sorbable and more easily handled material may 
or may not precede the final steel suture to 
determine the proper balance of the three 
variable factors involved, viz., amount of 
invaginated tissue, final restored muscle con- 
tinence and wound tension. The latter can be 
lessened even after final suture, if found to be 
desirable, by extending the peripheral incisions 
further but the effect of this on final continence 
must also be kept in mind. 

It is important to prevent cutting of the 
tissue by the steel suture over a prolonged 
period and for this purpose both ends of all 
mattress sutures are secured over baby buttons 
available at the dime store. We are positive that 
this detail of technic is a necessity and wish to 
emphasize that no confidence whatever is 
placed in anything but wire mattress sutures 
over buttons for any anal plastic surgery. Large 
substantial bites are likewise essential. A 
diamond-shaped defect will then be found to 
have formed lateral to the sutured flaps. One 
or more wire retention sutures, also with 
buttons, are placed here to relieve tension on 
the muscle suture. (Fig. 8.) The wound is not 
completely closed and, indeed, the skin edges 
should purposely be prevented from union 
before healing of the deeper tissue has taken 
place. 

We have followed these wounds carefully 
from day to day postoperatively frequently 

January, tq^o 


under pentothal. At present we routinely 
examine the wound thoroughly at the end of 
five days preferably in the operating room and 
under an anesthetic in order to remove sutures 
under too much tension and replace ineffectual 
ones. Thus at the least maximum protection is 
afforded the wound during the critical period 
of first bowel responses. This bother may seem 
out of proportion to the magnitude of the sur- 
gery but so is the outcome to the patient. There 
is tendency for both patient and surgeon to 
approach this operation too lightly simpl 3 '^ 
because it falls into a minor category. 

It requires a good deal of experience to 
assess the proper tension correctly and even 
buttons will easih'^ and do commonly slough 
clear through from pressure necrosis. Over and 
over again one tends to err on the side of 
excessive tension, a fault that is in some meas- 
ure counteracted bj^ the use of buttons, resuture 
of the wound and tenacious postoperative 
inspection and care. 

Surgical technic itself no matter how meticu- 
lous maj'’ prove futile unless maximum protec- 
tion is afforded^ the sutured sphincter. In 
addition to constant surveillance and certitude 
of suture effectiveness this is insured principally 
by preoperative and postoperative measures to 
defer bowel movements after surgery, to 
maintain soft consistency for some time and 
above all to prevent impaction and sudden 
explosive evacuations. Special care must be 
taken to avoid the latter on first bowel moxm- 



i8o 


Blaisdell — Incontinent Sphincter Ani 


ments following the long initial deferment. The 
judicious use of liquid and non-residue diet, 
enemas and/or cathartics for several days 
constitutes the mainstay of preoperative prepa- 
ration. Requisite postoperative care partakes 
more of the nature of personalized nursing on 
the part of the surgeon than is commonly asso- 
ciated. The intelligent use of retention enemas 
and in-and-out flushing of cleansing enemas 
are indispensable. The only suggestion outside 
of well known basic principles is a device em- 
ployed by us for the simultaneous use of 
continuous drip and suction in the rectum to 
prevent accumulation therein of stool. We 
made use of two very small urethral catheters 
fastened together and left in place simul- 
taneously, one for drip and one for suction. It 
was found advantageous to insert them to 
different levels inside the rectum and then to 
alternate their functions over periods of several 
hours. It is worth while experience to follow 
through these more meticulous preoperative 
and postoperative regimens with several ordi- 
nary rectal cases as rehearsals for achieving 
objectives when critical. 

SUMMARY 

It is reaffirmed that repair of the incontinent 
sphincter ani does not necessitate dissection 
and isolation and suture of the bare muscle 
ends. Instead, the use of muscle-bearing flaps 
is advocated. The principle was described by us 
several years ago in connection with one of the 
more unusual types of muscle injury. This 
paper reports an adaptation of this principle 
to the more common problems of repair with 
an even simpler operation. The technic of the 
operation is included and its advantages 
ennumerated. 

REFERENCES 

1. Blaisdele, Paul C. Operative injury to tlie anal 

■sphincter. J. A. M. A., 112: 614, 1939. 

2. Blaisdell, Paul C. Traumatic injuries of the 

rectum. J. A. M. A., 128: 559, 1945. 

3. Blaisdell, Paul C. Pathogenesis of anal fissure and 

implications as to treatment., Surg., Gynec. & 

Obst., 6$: 672, 1937. 

4. Blaisdell, Paul C. Repair of the incontinent 

sphincter ani. Surg., Gynec. & Obsl., 70; 692, 1942. 

5. Blaisdell, Paul C. Repair of the incontinent 

sphincter ani. Surg., Gynec. if Obst., 75: 634, 1942. 

6. Blaisdell, Paul C. The healing open pilonidal 

wound. J. A. M. A., 133: 916, 1947. 

DISCUSSION 

Harold Dodd (London, England): My pur- 
pose is to recall the usefulness and simplicity of 


Thiersch’s operation for anal incontinence and to 
describe an aseptic method of performing it. My 
notice was seriously drawn to the procedure by 
my former chief, Mr. Gabriel, in 1947 when he 
introduced a discussion on the subject at the Royal 
Society of Medicine in London. Thiersch must have 
practiced and taught the operation as early as 
1889 but I believe he never published it. Goldman 
reports on six patients treated by it in 1892, while 
Lenorant' collected thirty-four cases and reported 
them to the Society of Surgery of Paris in 1906. 

In a 150-pagc supplement of the Acta Chirurgica 
Scandinavica^ published last year Thiersch’s opera- 
tion was not mentioned, so it was either unknown 
or not considered worthj' of description. 

Thiersch’s operation consists of the insertion of a 
circle of silver wire around the anus. It is performed 
for loss of tone of the sphincter ani with rectal 
incontinence and for a patulous anus with or 
without some prolapse of the lower rectum. The 
patients who arc chiefly elderly, cachetic and 
fidgety women, suffer from an incontinent dis- 
charge of pellets of feces and mucus which neces- 
sitates their always wearing a diaper. 

The anal cleft disappears and the anus is level 
with the buttocks. Later a trumpet-Iikc presenta- 
tion of anal mucus membrane appears which may 
be followed by some prolapse of the lower rectum. 

Thiersch’s Original Operation. This was de- 
scribed by Lenorant of Paris in 1906: “A curved 
needle, armed with a strong silver thread is intro- 
duced at the level of the retro-anal raphe cm. 
from the anus. With it, one describes a trajectory 
round the anus to some c.xtent and one brings the 
needle out again. The needle is re-introduced at 
the c.xact point of convergence and this manoeuvre 
is repeated until the needle comes out at its place 
of original entry. The two ends of the wire are 
fastened.” 

Mr. Gabriel in his book® gives approximately 
the same directions for the operation using a 
Doyen’s curved needle to carry the wire. He has 
performed the operation sixteen times. 

It is my purpose to describe to you an aseptic 
method of introducing the wire. I think that as the 
area into which the silver wire is put is always a 
potentially infected one, it must be introduced 
ascptically; otherwise infection and pain may follow 
which would necessitate its removal. 

The skin of the buttocks is washed daily with 
alcohol. Sulfathaladine is given for four days 
beforehand to sterilize the alimentarj^ tract and 
penicillin and a sulfa drug twelve hours prior to 
the operation. A general or local anesthetic is 
equally satisfactory. 

The special instruments required consist of two 
large-bore aspirating needles such as could be used 
to aspirate a chest (they must be 4 to 5 inches long) 
and a piece of No. 19 or 20 gauge silver wire about 
10 inches in length. 

American Journal of Surgery 



Blaisdell — Incontinent Sphincter Ani 


i8i 



RELATION OF 
INCISIONS TO ANUS: 



posterior 

incision 




Fig. I 

The patient is placed in the lithotomy position 
with the buttocks raised on a pillow and protruding 
beyond the end of the operating table. The skin 
of the buttocks and the vulva are excluded by 
suitable draping. Two incisions } 4 , inch in length 
are made in the middle line, in front of and behind 
the anus beginning inch away from the anal 
verge. (Fig. i.) The needles and wire should be 
inserted without touching the skin. One needle is 
passed through the posterior incision and is 
directed forward circumferentially to the left of 
the anus, to % inch away and to inch deep 
to the skin. Its point emerges through the center of 
the anterior incision. The other needle is passed in 
a similar manner to the right of the anus. 

Owing to the laxness of the perianal tissues the 
needles raise two parallel folds of skin which hide 
the anus between them. (Figs. 2 and 3.) 

The silver wire, bent like a hairpin, is handled by 
forceps. (Fig. 4.) Its ends are threaded into the 
lumina of the needles from before backwards until 
they appear posteriorly through the shanks of the 
needles. They are seized and withdrawn to their 
full extent. This approximates the needle points so 
that the wire is scarcely visible between them. 
Traction on both the wire and the needles draws 
them deeply into the anterior wound between the 
retracted skin edges. (Fig. 5.) 

The needles are now removed, leaving the wire 
ends protruding through the posterior incision. 
These are firmly twisted four times with forceps, 

January, ig^o 




Blaisdell — Incontinent Sphincter Ani 


182 


having been pulled so as to embrace comfortably 
the proximal joint of an assistant’s index finger 
which has been inserted into "the anal canal for this 
specific purpose. Unless the wire ends are firmly 
secured, they may slip apart during the straining 
of defecation. The wire stump is inverted deeply 


carefully so that it gently encircles the proximal 
joint of the assistant’s index finger. 

Rationale of the Operation. Lenorant gave the 
following explanation of Thiersch’s operation: 
“According to Thiersch, the operation acts in two 
ways: the mechanical action of the wire in replacing 



Fig. 3 



Fig. 4 


into the fat to lie away from and not to irritate the 
skin. (Fig. 6.) 

In one patient I had to replace a broken stainless 
steel wire. In another woman with an extreme 
degree of laxness and mucosal prolapse I inserted a 
second wire inch external to the first. 

Lenorant describes a patient who, after the wire 
was inserted too tightlj% suffered from fecal impac- 
tion of the rectum and digital emptying was 
required. This is a reminder not to make the ring 
too small and to estimate the size of the ring 


WIRE LOOP DRAWN INTO INCISION 
WITHOUT TOUCHING THE SKIN 



Fig. 6 


the relaxed sphincter, and the presence of a foreign 
body in the perianal tissues encouraging cellular 
proliferation and bringing about a solid adherence 
between the rectum and the neighboring parts. 
Thiersch hoped to be able to remove the wire when 
the result had been obtained, but on this point the 

American Journal 0/ Surgeryr 


Blaisdell — Incontinent Sphincter Ani 


183 


facts have contradicted liim. Whenever the wire is 
broken or removed, prolapse again occurs.” 

Lenorant’s opinion of forty-three years ago holds 
true today. Messrs. Gabriel and Abel and other 
British surgeons have recently spoken of its useful- 
ness. It does relieve patients of their incontinence 
of feces. 

The Aftercare. Patients are instructed to keep 
their stools soft but formed and to obtain a daily 
evacuation. Watery stools may leak partly while 
impacted feces may require digital removal; or 
if the wire has been drawn too tightly, enlargement 
of its ring will be necessary. 

A glycerine suppository or enema may be neces- 
sary daily. 

Regarding the Thiersch operation of sixty years 
ago, I am reminded of a saying by Mr. Deansley, 
late surgeon of Wolverhampton: “What’s new 
isn’t necessarily true, and what’s true, isn’t always 
new.” The Thiersch operation is a useful, simple, 
rapid procedure for the tiresome condition of anal 
incontinence in older patients. It makes them much 
more comfortable physically, they feel secure and 
they are able to get about and take part again in 
life’s activities. Further, the procedure can also be 
used to supplement a larger operation for complete 
prolapse of the rectum in which the anus remains 
gaping open. 

To recapitulate, Thiersch’s operation is valuable 
for some patients with incontinence of feces and 
prolapsus mucosus recti. The wire must be inserted 
aseptically and must be of sufficient size to fit the 
proximal joint of the assistant’s finger. Immediate 
relief is bestowed. 


REFERENCES 

1. Lenorant. Bull. Mem. Soc. de Cbir. de Paris, 32: 

10, 1906. 

2. Ano Rectal Infections and Anal Incontinence. Acta 

cbir. Scandinav., Supplement 135, p. 96, 1948. 

3. Gabriel, William B. The Principles and Practice of 

Rectal Surgery. 4th ed., p. 1 33-1 59. Springfield, 

III., 1948. Charles C. Thomas, Publisher. 

Paul C. Blaisdell (Pasadena, Calif.): We are 
grateful for the description of the silver wire opera- 
tion which Mr. Dodd has presented. It would have 
obvious use when the sphincter muscle was absent, 
paralyzed or injured beyond hope of repair. Or, in 
conjunction with operations which envision return 
of function, such as our own, the silver wire might 
well be used with advantage to extend protection 
during the critical period of healing and recovery. 

These meetings were ushered in with a quotation 
from an American author, quoted by our English 
guests. Perhaps it is fitting, therefore, to close with 
a quotation from an English author. One of the 
lines which has stayed with me over the years is 
from Browning’s “Andrea Del Sarto,” telling of 
the “faultless painter.” This remarkable fellow 
dashed off superb paintings without effort whereas 
his confreres toiled at great lengths with vastly 
inferior results. It is rather apropos to most in our 
profession who have to strive so hard for so little. 
At times, when it is most discouraging, these words 
of Browning come to mind: 

“Ah, but a man’s reach should exceed his grasp. 
Or what’s a heaven for?” 




January, rg^n 



hst Imports 


ENTERIC'COATED PILLS AS A CAUSE OF FECAL 

IMPACTION 

Leonard J. Schwade, m.d. 

Milwaukee, Wisconsin 


F ecal impaction occurs when severe con- 
stipation results following the accumula- 
tion of inspissated feces in the colon or 
rectum. A fecal mass of doughy or putty con- 
sistency to one of hard and rock-like consistency 
may form. Although the rectum is the most 
frequent site of impaction, it may occur in any 
part of the large bowel and in diverticula. 
Carmeb classifies impactions as follows: (i) 
those which delay passage of fecal material 
through the colon; (2) those which increase the 
consistency of the feces and (3) those w'hich 
eause a diminution in the normal quantity of 
mucus produced by the mucous membrane of 
the large intestine. This report is chiefly con- 
cerned with the first category. 

Foreign bodies are frequent causes of ob- 
struction in the gastrointestinal tract. Such 
common objects as nails, chicken bones, safety 
pins, tootpicks, hairpins, bottle openers, 
bottles and enema tips may be injected or in- 
serted rectally intentionally or accidentally. 

The report of this case is unusual in that 
enteric-coated pills produced fecal impaction. 
Fecal impaction as a complicaton increases 
the difficulties of management and may present 
a perplexing problem to the attending physi- 
cian. A careful search of the American literature 
has failed to reveal any cases of fecal impaction 
directly caused by the accumulation of enteric- 
coated drugs in the large bowel. Because 
enteric-coated medication is so often used, it is 
our belief that fecal stasis from this cause occurs 
more frequently than is realized. It is of special 
significance in bedridden and debilitated pa- 
tients if the enteric-coated tablets are used 
without attention being directed to the ability 
of the patient to utilize such medication. 

The desirability of using Jenteric-coated 
medication has been discussed elsewhere.- 
Excellent investigative and experimental work 


on the value and use of enteric coating has been 
carried out recently by Wolffe,® Bauer and 
Masucci,'* and many other investigators. Wolffe 
noted a striking lack of uniformity in the 
therapeutic effects of two well known brands 
of enteric-coated ammonium chloride tablets 
when used in conjunction with mercurial 
diuretics in patients w'ith congestive cardiac 
failure. One brand proved its inefficiency by 
not only failing to disintegrate in the stomach 
but passing through the entire digestive tract 
practically unchanged. The other brand de- 
feated the purpose of the coating entirely by 
disintegrating in the stomach. In a personal 
communication to the author Wolffe describes 
three cases of fecal impaction caused by failure 
of enteric-coated pills to disintegrate. In these 
cases the pills passed through the small intes- 
tine and formed the nucleus of the impaction. 
All three patients suffered primarily from con- 
gestive heart failure and coronary insufficiencJ^ 

CASE REPORT 

A seventy year old white male was seen on 
January 4, 1947. He complained of rectal pain of a 
bearing-down nature which he attributed to the 
presence of an enema nozzle tip which he claimed 
had been left in his rectum following an enema 
several hours before. He was being treated for 
acute coronary thrombosis of approximately two 
weeks’ duration. He had been progressing satis- 
factorily until this incident occurred. The patient 
stated that he had been bothered with inside piles 
and a mild form of constipation for many years 
but was able to have satisfactory evacuations after 
taking an occasional mild laxative. 

During the previous week he had noted increas- 
ing constipation and was receiving daily soap and 
water enemas with only moderate relief. The last 
few days he had also complained of mild abdominal 
distention, gas pains and an inability to pass flatus 
satisfactorily. Although there was a sensation of 
fullness in the rectum, it was not until after the last 

184 American Journal of Surgery 


1 




Schwade — Fecal Impaction 


185 


enema had been given that he complained of the 
sensation of something sticking in his rectum. 

On examination the patient was propped up in 
bed. He was not acutely ill but was uncomfortable 
because of rectal pain. The abdomen was moder- 
ately distended and tympanitic. No masses were 
palpable. Proctologic examination revealed large, 
pendulous, thickened anal and perianal skin folds 
and moderate external hemorrhoids in all quad- 
rants. There were multiple, small, superficial anal 
fissures with a deep anorectal fissure in the pos- 
terior midline that was extremely painful to 
palpation. Sphincter tonus was moderately spastic 
due to pain but the anal apperture itself appeared 
larger than average. Digital examination beyond 
the anorectal junction revealed moderate pro- 
lapsing folds of rectal mucosa and a firm but boggy 
mass at the extreme distal end of the examining 
finger which was interpreted to be a fecal impaction. 
No foreign object such as an enema nozzle could be 
felt. The anoscopic examination called forth loud 
protests of pain with no cooperation on the part 
of the patient. It was decided, therefore, to carry 
out the remaining examination and proctosig- 
moidoscopy under local anesthesia. A flat plate 
roentgenogram of the abdomen and pelvis disclosed 
no evidence of a radiopaque foreign body such as 
an enema tip nozzle. Instead many button-like 
shadows clustered together in the rectum and 
throughout the descending colon and sigmoid were 
seen associated with some rectal dilatation. 

Immediate treatment for the relief of the fecal 
impaction was initiated with the use of enemas as 
follows: 800 cc. of equal parts of warm water and 
mineral oil retained for thirty minutes evacuated 
and followed by 400 cc. of equal parts of hydrogen 
peroxide and water, evacuated immediately and 
finally followed by 800 cc. of clear, warm water 
which was evacuated. The results obtained were 
excellent as the patient evacuated large lumps of 
fecal material followed by a great flow of soft, 
mushy feces. The feces contained the many button- 
like structures seen on the x-ray films. These made 
up the nucleus of the fecal lumps. They proved to 
be undigested, enteric-coated ammonium chloride 
tablets which the patient had been taking as a 
diuretie. (Fig. i.) 

Evidently the enteric-coated pills had failed to 
disintegrate and had passed through the small 
intestine and colon finally lodging in the rectal 
ampulla. Here they had mixed with the feces 
forming a nucleus for the impaction. The pills 
following became further lodged being unable to 
pass the obstruction and thus filled the entire 


sigmoid and left colon. Straining and trauma 
following the enemas caused the development of 
multiple anal fissures and consequent pain which 
the patient had assumed was caused by a lost 
enema tip. 



Fig. I. Fecal impaction with enteric 
coated ammonium chloride tablets 
visible in the sigmoid colon and 
rectum. 

Subsequent digital and sigmoidoscopic, examina- 
tion disclosed large, prolapsing, internal hemor- 
rhoids but no other disorder. The patient had 
natural bowel movements following the passage 
of the impaction and continued to pass the enteric- 
coated tablets with his stools for the next two days. 

It is not our desire to speak against the use of 
medicaments covered with some form of enteric 
coating but rather to caution the physician to study 
each case and medicament according to the pa- 
tient’s condition so that fecal impaction from this 
cause may be prevented. 

SUMMARY 

Enteric-coated tablets failing to disintegrate 
in the small intestine may become deposited in 
the large bowel and disturb the normal fecal 
flow causing fecal impaction. 

REFERENCES 

1 . Carmel, A. G. Fecal impaction. Report of ten cases. 

J. Med., 17: 448-453, 1936. 

2. Brochure on “Enseals.” Indianapolis, Indiana, 1048. 

Eli Lilly Co. 

3. WoLFFE, J. B. What value enteric coating. Am. J. 

Med., 5: 87-89, 1948. 

4. Bauer, C. W. and Masucci, P. E. J. Am. Pharm. 

A., 37: 124, 1948. 




Januaryr, ig^o 



ISCHIO'ANAL ABSCESS DUE TO FAULTY TECHNIC OF 
PUDENDAL BLOCK IN OBSTETRICS 


G. J. Rilling, m.d. 
Philadelphia, Pennsylvania 


D ue to faulty technic a number of inter- 
esting cases has been reported in which 
the anus, rectum or sigmoid was in- 
jured or perforated with enema tips or the 
sigmoidoscope^"’’ It is with this thought in 
mind that I am presenting the following report. 
Several papers on pudendal block have ap- 


Figure i shows the principle of pudendal 
block as described in this report. 

Bilateral intradermal wheals are made mid- 
way in a triangle whose apices are represented 
by the tuberosity of the ischium, the symphysis 
pubis and the anal opening. The injections arc 
made from this point. 



peared in the literature since 1910. Among the 
advantages of this technic are the following: It 
may be used when the patient is confined at 
home; the patient remains conscious; an epi- 
slotomy may be performed and repaired with- 
out additional anesthesia and there is practically 
no maternal or fetal mortality following this 
procedure.'* The effectiveness of this technic 
lies in the adequate blocking of the pudendal, 
ilio-inguinal and inferior hemorrhoidal nerves. 

Pudendal block is performed® when the 
progress of labor has advanced to the stage of 
complete dilatation of the cervix by rectal 
examination in the multiparous patient or has 
reached the perineal stage in the primiparous 
patient. 


The pudendal nerve is blocked as it emerges 
from Alcock’s canal medially to the ischial 
tuberosity. The ilio-inguinal nerve is blocked 
as the nerve passes over the symphysis. The 
inferior hemorrhoidal nerve is blocked as close 
as possible to the levator ani fascia.® The reason 
for blocking the inferior hemorrhoidal nerve at 
this location is that the nerve does not always 
arise from the pudendal nerve but occasionally 
arises directly from the sacral plexus.^ 

Normally the anal opening is slightly pos- 
terior to a line drawn between the two ischial 
tuberosities. With the head pressing on the 
perineum the rectum and anus are displaced 
backward and the sphincteric fascia is markedb'^ 
thinned. The object of this procedure is to have 

American Journal of Surgery 


186 



Rilling — Ischio-anal Abscess 


187, 


the anesthetic injected as close as possible to 
the dilated levator ani fascia covering the 
sphincters. It is at this point that the inferior 
hemorrhoidal nerves are anesthetized. 

To the educated finger there is little danger 
of puncturing the over-stretched fibers of the 


such as pain, tenderness, swelling, redness and 
induration over one or both ischio-anal fossae 
associated with fever, leukocytosis and toxemia. 
The procedure of pudendal block was immedi- 
ately discontinued until the cause of these 
complications could be determined. Cultures 


Table i 


Case 

Para 

Age 

Date of 
Pudendal 
Block 

Episi- 

otomy 

and 

Suture 

Rectal 
Symp- 
toms 
Prior to 
Child- 
Birth 

First 

Symp- 

toms 

Noted 

(Pain) 

Date of 
Consul- 
tation 

and Ex- 

< 

amma- 
tion by 
Rectal 
Dept. 

Location 

Ischio- 

anal 

Abscess 

Incised 

Dis- 

charged 

1 

Subse- 

quent 

Rectal 

Symp- 

toms 

M. B. 








i 

i 




#16415 

B. S. 

It 

25 

5/16/46 

Yes 

None 

5/ 19/46 

5/24/46 

Right 

5/24/46 

5/30/46 

None 

#16502 

1 

M, W. 


19 

5/14/46 

Yes 

None 

5/16/46 

5/25/46 

Bilateral 

Left side 
5/25/46 
Right 
side 

5/31/46 

6/6/46 

None 

#16744 

M. W. 

I 

24 

5/9/46 

Yes 

None 

5/13/46 

5/27/46 

Right 

Refused 

opera- 

tion 

6/6/46 

None 

#18070 

B. P. 

I 

15 

5/22/46 

Yes 

None 

5/24/46 

5/27/46 

Bilateral 

Left side 

5/27/46 

Right 

side 

5/31/46 

6/21 /46 
G. C. 
Infection 

None 

#15360 

H. H. 

I 

18 

5/17/46 

Yes 

None 

5/20/46 

5/31/46 

Right 

5/31/46 

6/7/46 

None 

#16748 

1 

17 

5/25/46 

Yes 

None 

5/29/46 

5/31/46 

Bilateral 

Both 

sides 

5/31/46 

6/6/46 

None 


fascia. However, the use of improper technic 
will permit one to penetrate this fascia readily 
and involve the sphincter ani muscles, anal 
canal or rectum. Following aspiration and in- 
jection of the solution the needle is slowly with- 
drawn. At the time of this breach of technic 
there is danger that the colon bacillus may 
infect the ischio-anal fossa thus producing 
abscess formation. 

In the hospital with which I am affiliated 
pudendal block had been a popular method of 
obstetric analgesia for over a year and we were 
unaware of any rectal complications. From 
May 24 to 31, 1946, we were consulted about 
several complications, all of which followed an 
attempt at local anesthesia. Without any ap- 
parent reason six patients developed symptoms 

Janxiarir, jpyo 


were made of the solutions, instruments and 
dressings as well as pus from the abscess. The 
solutions, instruments and dressings proved to 
be sterile but the pus showed the presence of 
Escherichia coli. 

Table i shows the record which gives a 
history of the former six patients who had had 
pudendal block and the procedures which had 
been performed by three different resident 
physicians. 

The patients were Para i and Para ii and 
varied in age from fifteen to twenty-five years. 
In all an episiotomy had been performed on 
the left side and sutured without any apparent 
evidence of infection which could contribute 
to these abscesses. There were no rectal symp- 
toms prior to childbirth. The first evidence of 









,100 


rviiiing — isoiiio-aiiai /\Dscess 


rectal involvement was pain noted two to four 
days following delivery. 

Bilateral ischio-anal abscesses developed in 
three patients. In the other three an ischio-anal 
abscess developed only on the right side. 

In five of the patients symptoms had been 
present for six to fifteen days before consulta- 
tion and examination were requested. The 
treatment consisted of immediate radical in- 
cision and adequate drainage which was per- 
formed after the first e.xamination. A careful 
search was made to determine the presence of 
an internal opening in the anal canal ‘but no 
internal opening could be located. One patient 
refused operation, and examination eighteen 
days postpartum following the use of penicillin 
and sulfadiazine showed that the infection 
gradually subsided with entire resolution. 

In one patient both ischio-anal areas were 
involved at one time. In two patients the 
opposite ischio-anal area became involved four 
to six days following the original infection. 
After radical incision and adequate drainage 
there was no tract located between these two 
ischio-anal abscesses. 

Four of the patients were discharged about 
six days following the last operation. One pa- 
tient had refused operation; the other patient 
who also had a gonococcal complication was 
hospitalized for twent^^-one days following her 
last operation. 

After two and a half years the Social Service 
Department reports no further evidence of this 
infection. 


CONCLUSIONS 

Pudendal block is a procedure which is being 
used routinely by a number of obstetricians 
and is apparently gaining in favor. 

Residents and internes are being trained in 
the technic of this procedure. However, it has 
been shown that lack of experience and faulty 
technic will result in the development of an 
ischio-anal abscess. 

The usual cause of an ischio-anal abscess is 
from an infection in a crypt of Morgagni. SLx 
cases of ischio-anal abscess due to faulty 
technic of pudendal nerve block are presented 
in which no disorder was found in the anal 
canal or rectum. 

REFERENCES 

1. Ault, Garnet \V. Perforation of the rectum with 

enema tips. Tr. Am. Prod. Soc., pp. 203-213, 1939. 

2. Pfeiffer, Mildred C. J. Rupture of the recto- 

sigmoid during sigmoidoscopy. Am. J. Surg., 75: 
281-282, 194.8. 

3. Andresen', Albert F. R. Perforations from proc- 

toscopy. Gastroenterology, 9: 32-43, 1947. 

4. Waldman, I. J. Pudendal anesthesia. Wisconsin M. 

J., 38: 5S2, 1939- 

5. Bonim, Louis A. The effect of local anesthesia by 

means of pudendal nerve block tvith novocain on 
cervical dystocia occurring late in the first stages 
of labor. Am. J. Ohst. «** Gynec., 45: 805, 1943- 

6. Sen ADEL, Lees M., Jr. A method of obstetric 

analgesia and anesthesia. Am. J. Ohst. 6* Gynec., 
55: 1016-1021, 1948. 

7. Gray’s Anatomy. 25th ed., p. 996. 




American Journal oj Surgery 


COLOVESICAL FISTULA 

James T. Jenkins, m.d. 

Peoria, Illinois 

T he accepted treatment of choice of colo- a right herniorrhaphy with a history of urinary 
vesical fistula is an early transverse difficulty beginning one week after his discharge 
colostomy followed by a resection of the from the hospital. He had frequency every two 




Fig. I. Spot film of sigmoid 1941 reveals diverticula with narrowing of the 
sigmoid. 

Fig. 2. Spot film of sigmoid five years later with almost complete obstruc- 
tion of the sigmoid. 


fistula and a portion of the sigmoid, if neces- 
sary, whenever this procedure is feasible. In 
the two cases reported this procedure was not 
possible. 

CASE REPORTS 

Case i. A white male, aged sixty, entered the 
hospital on December 22, 1946, three months after 

January, ig^o 


hours during the day and night with tenesmus, 
burning and a bubbling of gas at the end of urina- 
tion. One week prior to the present admission he 
passed fresh blood and some clots at the end of 
urination. In 1941 a diagnosis was made of diver- 
ticulitis of the sigmoid and he had had “colitis” at 
intervals since that time. (Fig. i.) 

Physical examination revealed nothing abnormal 
except mitral regurgitation and tenderness in the 

189 



Jenkins — Colovesical Fistula 


190 



Fig. 3. Devine colostomy-skin separates the two 
stomas, the left or proximal one being the larger. 

left lower quadrant of the abdomen. The urine 
contained both red and white blood cells. He had a 
temperature for three days of io2°f. Sigmoidoscopy 
under anesthesia revealed at 12 cm. a marked 
narrowing of the rectosigmoid with some fixation 
anteriorly. The scope was passed with difficulty 
for 20 cm. A barium enema revealed sigmoiditis 
with partial obstruction. (Fig. 2.) Cystoscopic 
examination revealed no pathologic condition. 

Oral medication consisted of sulfathalidine, 2 
Gm. four times a day and gentian violet (enteric 
coated), .065 Gm. three times a day before meals. 
Hot rectal irrigations were given daily. Three days 
later gentian violet was recovered in the urine. The 
bubbling of gas at the end of urination continued. 

A diagnosis of diverticulitis with colovesical 
fistula was made. At the time of surgery the bladder 
was found to be firmly fixed to the sigmoid and 
could not be separated. A colostomy employing 
the technic of Devine was done, using a Daniel 
clamp to the proximal stoma. Recovery was com- 
plete. (Fig. 3.) 

The patient was seen last in April, 1948, and his 
condition was good. He complained of some liquid 
being passed through the distal stoma and through 
the rectum. At 7.5 cm. the sigmoid was firmly 
attached to the posterior wall of the bladder with 
much induration and inflammatory tissue sur- 
rounding the entire area. The patient was again 
given gentian violet orally. He has failed to return 
for subsequent examination. 

Case ii. A white male, aged sixty-nine, was 
admitted to the hospital on November 18, 1945, 
and assigned to the urologic service of Dr. Arthur 
Sprenger. His chief complaints were; urethral dis- 
charge at irregular intervals, the passage of gas by 
urethra for several months and pain in the lower 


portion of the abdomen. A change in bowel habit 
consisting of alternating constipation and diarrhea 
had been present for six months. 

E.vamination showed the patient to be edentu- 
lous. His abdomen was distended and there was 
tenderness in the suprapubic region. The urine 
contained 35 pus cells per low power field. Estima- 
tion of the non-protein nitrogen was 30 mg. per 
100 cc, of blood; the serum protein, 7.9 Gm., 
globulin 2.7 Gm. and albumin 5.1 Gm. with an 
albumin-globulin ratio of 1.9. The prothrombin 
time was twenty-nine seconds, the icteric index 
was 4.9 and the Kahn reaction of the blood was 
positive. 

Examination of the colon- by barium enema 
revealed a partially obstructing defect of the 
sigmoid colon, probably a malignant lesion and 
divcrticulosis of the colon. (Fig. 4.) A cystogram 
showed slight prostatic enlargement along with a 
defect of the upper surface of the bladder, con- 
sidered to be neoplastic, and separated by some 
distance from the sigmoid lesion. On November 
19th cjfstoscopic examination revealed, on the wall 
of the bladder, a caulillower-like growth involving 
the entire right side of the bladder and appearing 
to be carcinoma. Urine culture on this date re- 
vealed many gram-positive cocci and some gram- 
negative and gram-positive bacilli. On November 
26th sigmoidoscopy was done. Scope was passed 
20 cm. where it was impossible to proceed due to a 
narrowing and induration. (Fig. 5,) A sharp 
angulation to the left could be seen. On November 
29th a blood culture was negative throughout. 

The patient was given hot irrigations by rectum 
three times daily and sulfathalidine was given 
orally in doses of 2 Gm. four times daily’. One week 
later the second attempt to pass the sigmoidoscope 
bey’ond 20 cm. also was unsuccessful. No evidence 
of carcinoma could be found. 

On December nth cy’stoscopic examination was 
done by Dr. Sprenger. Turbid urine was evacuated 
from the bladder. The mucosa of the bladder was 
inflamed but there was a marked regression of the 
lesion seen at the last examinat'on. It was now 
assumed to be inflammatory in character and not 
malignant. No opening in the bladder which might 
communicate with the bowel could be found even 
though the patient stated that he passed gas 
through the bladder. 

His course in the hospital to December 15th was 
uneventful. His temperature which had remained 
normal rose to ioi°F. On urination following an 
enema the specimen appeared as liquid stool and 
had a foul odor. The patient complained of general 
malaise, became very irritable and insisted some- 
thing be done. His temperature spiked to io 2 °f. 
daily. On December 19th the patient was irritable 
and complained bitterly’. He stated that if some- 
thing was not done within twenty-four hours, he 
would go home. The foul-smelling urine continued. 

American Journal of Surgerxr 




Fig. 4. Dilated transverse colon and diverticula of the 
descending and sigmoid colon. 


Fig. 5. Spot film of sigmoid revealing almost complete 
obstruction in this area. 
















wmwm 


mm 








■w . ' f *t »'• 






m. 

Fig. 6. Postmortem specimens revealing foreign (piece of oak floor board 3 cm 
ufinly biLTr® «nd abscess cavity which had perforated 

w'l; /■ specimen with probe in sinus connecting the urinarv 

bladder and the sigmoid colon; the foreign body may also be seen. ^ 


January, ig^o 


192 


Jenkins — Colovesical Fistula 


In consultation with Dr. Sprenger it was decided 
his fever for the past four days was due to an 
ascending pyelitis and an immediate short circuit- 
ing of the fecal stream was decided upon. 

On December 20th under intravenous anesthesia 
the abdomen was opened through a left rectus 
incision. The subcutaneous fat seemed edematous 
and the muscle was dark reddish brown in color. 
Considerable clear fluid escaped on opening the 
peritoneum. The liver was normal to palpation and 
the gallbladder was small. No nodes were found. 
There was a soft mass in the left iliac region about 
3 inches in diameter. The sigmoid was firmly 
adherent to the posterior wall of the bladder. The 
colon was movable except where it was attached 
to the bladder. A colostomy was done following the 
technic of Devine. The fascia and peritoneum were 
closed with wire and the skin with clips. His tem- 
perature at this time was io 2 °f. 

During the first week postoperativciy a Folej' 
indwelling catheter allowed continuous bladder 


drainage to be obtained. He had developed a pro- 
ductive cough and was being treated with penicillin 
and supportive therapy. The postoperative eourse 
was stormy with bilateral bronchopneumonia 
developing two days postoperativciy. A downward 
course continued and the patient died of pneu- 
monia on January 3, 1946. 

The autopsy report included the following 
pertinent findings: (i) A foreign body in the sig- 
moid colon, a piece of wood, measuring 3 cm. by 
0.3 cm. (Figs. 6 and 7); (2) sinus tract between the 
sigmoid and bladder; (3) fetid cystitis; (4) broncho- 
pneumonia of both lungs and (5) double barrel 
colostomy. 

The foreign body recovered from the sigmoid was 
a piece of oak flooring. The patient’s son volun- 
teered the information that his father, who was a 
carpenter by trade, had been working on hardwood 
floors for the month previous to hospitalization 
and that he was in the habit of carrying a toothpick 
in his mouth mucii of the time. 




American Journal of Surgery 



ANORECTAL MALIGNANT MELANOMA=^ 


Alexander E. Rosenberg, m.d. 
Miami Beach, Florida 


D r. W. G. MacCallum in the second 
edition of his “Text Book of Pa- 
thology” notes a case of melano- 
sarcoma which arose in a healing hemotoma 
under the thumbnail, with numerous metas- 
tasis and death a few months after the first 
injury. I am not suggesting that there was any 
trauma induced by the injections of penicillin, 
but in view of Dr. MacCallum’s case the 
coincidence is worth noting as demonstrated in 
the following: 

CASE REPORT 

This patient was a married, white male, twenty- 
eight years old, who was a former football guard at 
college and a marine sergeant. He had enjoyed 
unimpaired health most of his life. About five 
months before admission he developed a urethral 
discharge. He was given an intramuscular injection 
of penicillin in the right buttock daily for three 
days. During the following month he developed 
pain and swelling in this same region. 

These symptoms increased in severity and the 
condition was diagnosed as an ischiorectal abscess. 
The lesion was incised under sodium pentothal 
anesthesia, with the evacuation of a few cubic 
centimeters of a thin, cloudy fluid. The operative 
wound continued to discharge for the next three 
months. The patient was then transferred to 
another hospital in which a diagnosis of chronic 
ischiorectal abscess was made. He was advised that 
further surgical intervention was necessary. The 
original incisions were made longer, the sub- 
cutaneous tissue and fat were mobilized and all 
granulation removed by curettement and dissection. 

Adequate doses of chemo- and antibiotic therapy 
failed to influence the course of the process. The 
wound kept filling up with what was believed to be 
granulation tissue. The discharge which was pro- 


fuse became serosanguineous and altered with 
frequent intervals of persistent bleeding. 

This then was the condition of the patient when 
I first saw him five months after the onset of 
symptoms. He had lost 40 pounds in the interim 
and appeared acutely ill. His temperature was 
elevated to io2°f. His pulse was rapid and weak. 
He coughed frequently, with the production of 
thin mucus. I will relate here only the pertinent 
findings. 

Presenting through and overlapping the right 
ischiorectal space with obliteration of one-third 
of the buttock on its medial side was a large, 
sharply demarcated, semi-spherical mass approxi- 
mately 12 cm. in diameter. It was black, somewhat 
lobulated, ragged, moist, jello-like in consistency 
and friable. Its fresh cut surface revealed a fine 
honeycomb of gray supporting structure. The 
margins of the wound were inflamed and covered 
with numerous islands of soft granulation. How- 
ever, it was not adherent to the main mass at any 
point except to the right side of the anal wall which 
was indurated and the mucosa above deeply con- 
gested and edematous. It was believed that the 
tumor arose at this level. It gave the appearance of 
having pushed through the fossa and its overlying 
structures. Sections were taken from the center, the 
periphery and deeper parts for microscopic study. 
A diagnosis of malignant melanoma was made with 
no suggestion as to its primary site as it was impos- 
sible to identify the cells other than that they were 
large, irregular polygonal forms with deeply pig- 
mented granules resting on delicate stroma. 

An x-ray study of the chest revealed a single, 
large, egg-shaped mass about 3 cm. long and 2 cm. 
wide in the parenchyma of the right lower lobe. 

The patient’s condition deteriorated rapidly 
culminating in early signs of obstruction, pulmo- 
nary edema and hemorrhage. An autopsy was not 
obtained. 


* U.S. Naval Hospital, Aiea T.H. 


>93 


January, 1950 



THORACOCOLONIC FISTULA* 


H. R. Reichman, m.d. 

Salt Lake City, Utah 


T his case is considered to be of interest 
for two reasons; (r) in a limited review of 
the literature no comparable case could 


fall of 1945 when because of a chronic productive 
cough and loss of weight she was again hospitalized. 
On November nth a thoracotomy was done for 



A 


' ■ A 

Fig. I. Photograph showing numerous openings of 
fistula; primary opening in chest at site of thoracotomy 
wound. 

be found; (2) it illustrates the severe systemic 
effects which can follow proctologic infections. 

CASE REPORT 

A thirty year old white female was hospitalized 
in June, 1942, for an e.xacerbation of polyarthritis, 
the severity of which was such that slight jarring 
of the bed caused her to cry out tvith pain. 

Roentgenographic e.xamination of the gastro- 
intestinal tract disclosed no pathologic changes. 
Estimation of the hemoglobin concentration 
sliowed marked anemia. 

I saw the patient for the first time then because 
of an e.vtensive perineal fistula which had ruptured 
in the vagina. The process was incised widely and 
drained June 3, 1942. Her general condition 
improved rapidly, her arthritic symptoms subsided 
completely and she was discharged from the 
hospital. 

In June, 1943, one year later, she returned to the 
hospital and her rectovaginal fistula was repaired. 
Her recovery was uneventful. During the preceding 
year she had gained 35 pounds, and her only 
residual complaint was a moderate degree of 
ankylosis of the cervical spine. 

This patient remained in good health until the 



Fig. 2. Colon x-ray study showing communication 
with thoracic fistula. 


drainage of an empyema secondarj’^ to a lung 
abscess and bronchopleural fistula. Her general 
condition improved but the thoracic fistula failed 
to heal. 

In the spring of 1946 lipiodol injected into the 
thoracic fistula appeared to empty into the intes- 
tine. During the past months there had been a 
recurrence of arthritic pains. She refused hos- 
pitalization for study and treatment of her condi- 
tion. Her symptoms increased and her general 
health declined. She re-entered the hospital in 
February, 1948. There was a marked exacerbation 
of all symptoms with a weight loss to 100 pounds. 
After each meal pus and feces would run from the 
openings now multiple in her left thorax and 
lumbar region. (Fig. i.) She had developed marked 
clubbing of her fingers which disappeared sub- 
sequent to colectomy. Roentgenographic examina- 

ofUtah School of Medicine, 


From the Proctologic Service of the Latter Day Saints Hospital, and the University 

Salt Lake City, Utah. 


194 


American Journal of Surgeiy 


Reichman — Thoracocolonic Fistula 


195 


tions at this time showed the colon to be diseased 
throughout with many polypoid tumors and the 
thoracic fistula was seen to communicate with 
the apex of the splenic flexure. (Fig. 2.) The 
stomach and duodenum appeared normal. Urog- 
raphy following the intravenous administration of 
the opaque medium showed the urinary tract to be 
normal. The concentration of hemoglobin was 
7.5 Gm. per 100 cc. of blood with 2,600,000 erythro- 
cytes and 7,400 leukocytes per cu. mm. of blood. 
There were 6.7 Gm. of protein per 100 cc. of serum. 
At the first stage an ileosigmoidostomy was done 
with side-to-side anastomosis of the terminal ileum 
to the distal sigmoid. The ileum distal to the 
anastomosis was wrapped with polythene; this in 
turn was wrapped with plain cellophane and 
sutured to the mesentery. This was done with the 
hope of gradually stenosing the lumen of the ileum 
and completely shunting the fecal stream from the 
fistula. The patient’s convalescence was uneventful. 

After preparation three weeks later the patient’s 
abdomen was reopened through the same midline 
incision and a right colectomy was done. A colos- 
tomy was made in the upper angle of the midline 
incision by bringing out the pro.ximal end of the 
distal third of the transverse colon. The splenic 
flexure was noted to be very adherent as formerly. 
The anastomosis was in excellent condition. 

The fistulous tracts in the lumbar region and 
thorax failed to heal or regress as had been antici- 
pated. Four weeks later the multiple sinus tracts 
in the left thoracolumbar region were incised and 
the necrotic tissue removed. This was done to 


provide more adequate drainage of the purulent 
material before the abdomen was reopened to 
remove the remaining portion of the colon con- 
taining the fistula. Cultures of this tissue showed 
no unusual organisms as had all previous cultures. 

Twenty-one days after this procedure the patient 
was again operated upon at which time the colos- 
tomy was closed. The abdomen was opened through 
the side of the previous midline incision and the 
distal portion of the transverse, the splenic flexure 
and the descending and proximal two-thirds of the 
sigmoid colon were removed. The lumen of the 
sigmoid just above the anastomosis was closed with 
a double row of chromic catgut reinforced with 
interrupted No. 40 cotton sutures. Two large tracts 
which readily admitted the index finger were, 
indentified; one extended into the thorax and the 
other to the lumbar region. The pancreas, spleen 
and left kidney appeared undamaged by the infec- 
tious process. Recovery from this operation was 
uneventful. 

The patient was advised to have a skin graft 
to the denuded area of the thoracolumbar region to 
shorten her convalescence. She declined because 
of the numerous operative procedures to which she 
had been subjected. The wound healed without 
incident. 

Her entire convalescence although prolonged was 
most satisfactory. All foods were well tolerated. 
She had normal bowel movements two to four times 
daily with good control. When last seen she had 
gained 40 pounds, was in good spirits and was 
symptom-free. 




January, /950 



EXTRAMAMMARY PAGET’S DISEASE 
OF ANO'COCCYGEO'SACRO'GLUTEII AREAS 


Thomas F. Nelson, m.d, 
Tampa, Florida 


AT the present time there are two schools 
of thought regarding the origin of 
extramammary Paget’s disease. One 
states that it is a panepidermotropic cancer 
migrating into the epiderma from the origin in 
deep tumors with no transition between normal 
epidermal cells and the Paget’s cells. The other 
school states that the disease is not associated 
with deep cancerous tumors but begins in the 
epithelium and invades the underlying tissue. 

The first extensive review of fifty-eight cases 
was by H. A. Weiner in 1937 in which only 
fifteen were accepted as authentic. Distribution 
was as follows: Perineo-ano-scrotal one, scrotal 
one, scrotal and penile two, axillary three and 
vulvar eight, with no concurrent underlying 
cancer. Stout has accepted Weiner’s view that 
they are associated with underlying apocrine 
sweat glands and that cancer is secondary. 
Hamilton Montgomerj’’ states that the disease 
is an epithelioma in situ of multicentric origin 
from the epidermis and dermal appendages. 
Many of the lesions reported will usually prove 
on microscopy to be squamous cell epithelioma 
with evidence of individual cell kertinization. 

The earliest case on record was in the perineo- 
ano-scrotal area and was reported by J. Darier 
in 1893. He classified the condition as dis- 
keratosis which is defined as an isolation and 
differentiation of certain epidermal cells under- 
going an abnormal mature and imperfect 
keratinization. In 1925 Arzt reported that in a 
small proportion of cases there is a precancerous 
condition with favorable prognosis. He stated 
that in the preponderance of cases a glandular 
cancer is concurrently present and cited ten 
cases of adenocarcinoma of the rectum having 
Paget’s disease of the anal region. 

The latest verified case of extramammary 
Paget’s disease was reported by Casper in 1 948- 
It is the ninth case of the vulva and the onl3’’ 
authentic report since 1937. This patient was 
a female sixty-six years of age in 1941 with only 
the complaint of itching eruption on the vulva. 
Treatment which was given for two years con- 
sisted of Vitamin a , 100,000 units three times 


daily, and 50 mg. of testosterone three times 
a week for a month, with six roentgen ray 
treatments. The lesion did not change in size 
or elevation but showed more oozing than 
before; according to the patient the itching was 
still unbearable, '\^hthin the nexi: two years she 
was seen twice; the lesion did not change 
clinicalljc Death was due to other causes and 
not to an underljnng cancer. 


CASE REPORT 

R. P. was a white British female, age si.xty-three, 
who resided on one of the very small isles south of 



Fig. I. Extramammary Paget’s disease of the ano- 
coccygeo-sacro-gluteii areas. 


Cuba. The past medical and surgical histories were 
negative. She had two children living and well. In 
December, 1946, an itching skin lesion was noticed 
by the patient on the right intergluteal area at the 
level of the coccyx. Within five months there was 
direct extension of the lesions to the opposite 
gluteus and in the following four months the addi- 
tional sj'mptoms of slight moisture and sanguinous 
staining was noticed when average ambulation 
created too much friction. The general physical 
examination was essentially negative except for the 
skin lesion described as follows: size 14 by 8 cm., 
circinated, with a sharply demarcated advancing 
border of a light amber hue, elevated 2 mm. above 
skin level; otherwise there was normal-appearing 
skin. 

The frictioned areas on each inner gluteal surface 
were well outlined; each contained moist, scarlet. 


196 American Journal of Surgery 



Nelson — Paget’s Disease 


197 



2 3 4 _ 

Figs. 2, 3 and 4. Photomicrographs (low, medium and high power magnifications) from extramammary lesion of 
Paget’s disease as seen in Figure i revealing an unusual overwhelming number of colonies of the Paget cells. 


granular verrucae. These were ulcerated and 
elevated 4 ram. above the skin level. Flat, finger- 
like projections having dry, pink and flaky surfaces 
extended peripherally from the edge of the fric- 
tioned areas. These projections gradually tapered 
and blended to within to i cm. of the advancing 
border of the entire skin lesion. The projections 
joined each other across the sacrococcygeal space 
which is between the two frictioned areas. The 
perianal border of the lesion appeared to avoid the 
anal mucosa but encircled the posterior half of the 
mucocutaneous junction. Ano-procto-sigmoido- 
scopic examination was negative. Nine months 
after onset a radical excision of the lesion was 
performed. The mucosa of the posterior half of 
the anal canal including the anorectal junction was 
removed and primary closure was carried out 
except for the perianal area. Within four weeks the 
patient was allowed to return to her home and has 
since enjoyed good health. (Fig. i.) 

The summary of the pathologic report is Paget’s 
disease of the perianal areas complicated by 
squamous carcinoma of at least grade u malig- 
nancy. Different sections showed only the status 
simplex epidermal origin in which there was a down- 
ward growth of overlying epidermis and superficial 


invasion with squamous cells exhibiting many 
hydropic cells. (Figs. 2 to 4.) 

COMMENT 

The nature of Paget’s disease is still con- 
troversial because of the diversity of the 
hypotheses. It rests with the dermatologist 
and the pathologist to solve the histogenesis 
of the Paget cell. 

REFERENCES 

1. Weiner, H. A. Paget’s disease of the skin and its 

relation to cancer of the apocrine sweat glands. 
Am. J. Cancer, 31 : 373-403, 1937. 

2. Stout, A. P. The relationship of malignant amela- 

notic melanoma. Am. J. Cancer, 33: 196-204, 1938. 

3. Montgomery, Hamilton. Early recognition and 

treatment of skin cancer. S. Clin. North America, 
17: 1249-1264, 1937. 

4. Darier, j. and Corrilaud, P. Paget’s disease in 

the region of the perineo-anale and scrotale. Ann. 
de dermal, et sypb., 4: 33-39, 1893. 

5. Arzt, L. and Kren, 0 . Die Paget "disease mit 

becondrer Berucksichtigung ihrer Pathogenese. 
Arch /. Dermal, u. Sypb., 148: 248-312, 1925. 

6. Casper, W. A. Paget’s disease of vulva. Arch. 

Dermal. O' Sypb., 57: 668-678, 1948. 




January, ig^o 



ftipm fead by Title 


CORRECTION OF FECAL INCONTINENCE FROM 
OPERATIONS INVOLVING THE TERMINAL BOWEL* 

W. Wayne Babcock, m.d. 

Philadelphia, Pennsylvayiia 


O perations on the terminal bowel, 
particularly those for fistula and malig- 
nant disease, are common causes for 
loss of anal control. There has been some tend- 
ency to scorn attempts to reduce this disability 
as compromising the radical character of the 
operation. Unquestionably the primarj^ object 
of these operations is to eliminate completely an 
infection or malignancy. We may compromise 
with the former toward the goal of better func- 
tion but we dare not sacrifice radicability with 
cancer. However, we should be logical and not 
sacrifice the normal anus and perineum for an 
error as to downward spread of cancer made by 
Mr. Miles forty years ago. Also, we should not 
neglect the vital lateral spread and form a 
pelvic diaphragm from peritoneum adjacent 
to the tumor nor overlook an invaded prostate 
or vagina in the radical operation. 

In operations for fistula-in-ano it is approved 
practice to open widely and drain freely every 
inflammatory tract, the resulting contaminated 
wound being permitted to close slowly by 
granulation, with extensive scar formation and 
impairment of fecal control. Attempts to excise 
the fistula completely and close the wound with 
sutures, even though the operation is delayed 
until the condition has reached a subacute 
or chronic stage, have been followed by such 
dangerous phlegmons as to have been largely 
abandoned. But it is evident that if we could 
but establish a relative sterility of the chronic 
fistulas and prevent septic contamination 
during the operation, primary excision and 
closure should succeed. Previous to World 
War I I had found such a method so successful 
that I adopted it for an antiseptic, one-stage 
excision and closure of 350 chronic purulent 
sinuses from gunshot wounds of bone and soft 
tissue with success in over 80 per cent.^ In these 


operations depth sterilization of the lining of 
the fistula was obtained by a 10 per cent solution 
of zinc chloride, a caustic disinfectant which, 
due to the keratin layer, does not attack un- 
broken skin but progressively invades other 
tissues. It is too dangerous for forcible injection 
into anal fistulas but may be applied on slender, 
cotton-tipped applicators to the lining of the 
fistula after which 3.5 per cent tincture of iodine 
is thoroughlj" injected through all fistulous 
tracts. (Fig. i.) The iodine has a special anti- 
septic value on mucous surfaces as it dries the 
surface and arrests mucus secretion which 
othenvise might wash bacteria to. the surface. 
To delineate and make sure that no part of the 
fistula is overlooked the tract or tracts are then 
distended with an alkaline ethereal solution of 
methylene blue* using a 2 cc. Luer syringe. The 
ether expands from the heat of the bod}' and 
the solution penetrates the fistula more 
thoroughly, staining its walls a deep blue color 
clearly recognized through the outer walls of 
the tract. 

All fistulas are sterilized and stained and the 
rectum occluded and sterilized with a gauze 
packing wet with the 3.5 per cent tincture 
of iodine which is also painted over all exposed 
surfaces. To prevent iodine burns on the skin 
the iodine is neutralized with compound solu- 
tion of mercuric chloridef which is also an 
efficient antiseptic. Incisions are made around 
each external fistulous orifice with a sharp 
scalpel and, guided by the surrounding blue 

* Saturated alcoholic solution of methylene blue, 
thirty; ether, thirty; i per cent solution of caustic 
potash, forty parts. 

t Compound solution of mercuric chloride (Vaichulis 
and Arnold); ethyl alcohol, 95 per cent, 600 cc.; 
acetone, 200 cc.; mercuric chloride, i Gm.; hydrochloric 
acid, 10 cc.; chrysoidin Y, 2 Gm.; water to make 
1,000 cc. 


From the Surgical Department of Temple University School of Medicine, Philadelphia, Pa. 

198 American Journal of Surgery 



Babcock — Fecal Incontinence 


•99 



Fig. I. The fistulous tract after sterilization and injection with tincture of iodine is delineated by inject- 
ing methylene blue solution. 

Fig. 2. Guided by the deep blue stain, the fistulous tract or tracts and their ramifications are exposed by 
sharp dissection and completely excised. 

Fig. 3. The muscular layers are united with buried interrupted sutures of No. 35 gauge stainless steel wire 
and the ends cut close to the knot. 

Fig. 4. Externally the wound is united with interrupted No. 35 wire, within the anus by No. 000 chromic 
catgut interrupted sutures. 


discoloration, each fistulous tract is followed 
and completely excised intact to the intestinal 
orifice. (Fig. 2.) Vessels are ligated with No. 36 
stainless steel wire tied in a single square knot 
with the wire ends cut very close to the knot 
and the divided muscular layers and mucous 
edges finally united accurately with No. 35 or 
36 wire while No. 00 or No. 000 chromic catgut 
is used for the closure of incisions within the 
anal orifice. (Figs. 3 and 4.) At the apex of 
the dissection care should be taken not to con- 
strict the lumen of bowel by sutures nor to leave 
an edge or ledge under which feces may in- 
filtrate. Therefore, it may be found advisable 
not to unite the mucous edges in this region. 
The wound is dressed with 2 per cent yellow 
oxide of mercury ointment and antibiotics are 
used during the healing period. If the skin 

January, ig^o 


becomes irritated, boric acid or aluminum 
acetate compresses may be substituted. With 
this operation, performed of course only after 
the acute inflammation has subsided, primary 
union without serious reaction was usual even 
before the antibiotic era. Most of these patients 
are healed and in condition to leave the hospital 
a week after the operation. If the anal control 
remains inadequate, an anoplasty may later 
be used. 

Retention of a functional anus has been a 
very important consideration in resections of 
the rectum for cancer situated 6 cm. or more 
above the anal margin. During the past twenty 
years I have not sacrificed the anus in any case 
in which the gro^vth did not extend below this 
level. With ineradicable extension of the 
malignancy to the liver or other parts a radical 



200 


Babcock — Fecal Incontinence 


operation with sphincter preservation has been 
used for growths 2 cm. or more above the anal 
canal while for anal carcinoma a well formed 
perineal colostomy has proved more acceptable 
to patients than the abdominal opening. 

To preserve the functional sphincters in 
resection of the rectum for malignancy one of 
five methods has been used. 

Anterior Resection luith End-to-end Anas- 
tomosis. This leaves the sphincters intact and 
is preferred in suitable cases in which the 
malignant lesion Is 8 cm. or more above the 
anal margin. With division of the rectum 4 cm. 
below the growth about 2 cm. of bowel are left 
above the internal sphincter for anastomosis. 
The difficulties and dangers increase with such 
an anastomosis below the peritoneal reflection 
and this is about the lowest level that it is 
practical. A pull-through type of operation is 
to be preferred, especially when the patient is 
obese and has a narrow pelvis. As leakage 
frequently occurs after a low rectal anas- 
tomosis, a cigarette drain through the abdom- 
inal wound, vagina or perineum is desirable; 
and the bowel should be decompressed during 
the immediate postoperative period. To elimi- 
nate the septic seepage and necrosis from 
sutures having capillarity we have made the 
anastomosis entirely with stainless No. 35 or 36 
interrupted wire sutures. Many of these pa- 
tients are healed and able to leave the hospital 
a week after anastomosis. 

Anterior Resection ivilb Posterior Anastomosis. 
The liberated loop of rectum and sigmoid with 
the aid of a long , folded gauze tape tied around 
the bowel during the abdominal phase is 
brought through a midline postanal incision 
and amputated, leaving a proximal and distal 
perineal colostomy. At a second stage the two 
new openings are eliminated by liberation and 
end-to-end anastomosis through the perineum. 

Anterior Liberation with Posterior Resection. 
After disinfecting and occluding the rectum 
with gauze wet with tincture of iodine a midline 
perineal incision is made through the posterior 
border of the anus and anal skin along the 
coccyx to its base. The incision is deepened 
through the ligaments along the right side and 
tip of the coccyx and then in the midline 
between the two halves of the levator ani. A 
finger is introduced between the levators and 
first on one side and then on the other the 
levator is elevated and divided close to or at a 
distance from the rectum depending upon the 


proximity of the cancer. It is particularly 
desirable to preserve the lower fasciculus and 
the puborectalias for its sphincter action. The 
rectum is completely divided just above the 
sphincters and hemostatic forceps are attached 
to the upper margins for traction. With lateral 
abdominal retractors enabling good visibility 
and working from each side anteriorly with 
curved scissors, the rectum is freed and 
separated from the deep urethra and prostate 
along Denonvilliers’ fascia, or from the vagina, 
and the liberation of the rectum in the pelvis 
completed. A folded gauze tape, which was tied 
about the mid-sigmoid as a guide to its lowest 
level of vascularity during the abdominal part 
of the operation and then packed against the 
floor of the pelvis, is withdrawn with the bowel 
which is wrapped in a towel and laid over the 
pubis. Aided by lateral retractors and a trowel 
anteriorly the wound and pelvis are examined 
and any necessarj' hemostasis completed. If the 
prostate has not been resected, no ligations may 
be required. The residual halves of the levator 
ani are united with at least two la3"ers of inter- 
rupted No. 32 stainless steel wire with knots 
on the inferior surface of the muscle and the 
wires are cut off close to the knot. This forms a 
pelvic floor and restores the anterior angulation 
of the anus and terminal rectum. The divided 
sphincters are not united. The pelvic floor is 
sutured in three or four layers with Interrupted 
No. 32 wire sutures without drainage giving it a 
total depth of about 7 cm. Great care is 
taken that the withdrawn sigmoid remains free 
from constriction and thus retains an un- 
impaired circulation. Since the bowel continues 
to have longitudinal peristaltic contractions, it 
is not sutured to the skin or pelvie floor. 
Sterilization of the open bowel by iodine and 
elimination of perineal drains have been fol- 
lowed by relative freedom from Infection in the 
perineal wound. In the last 100 cases even 
trivial infections have been rare. To protect 
the perineal wound from fecal soiling the with- 
drawn bowel is divided about 10 cm. bej^ond 
the skin, a rectal tube is tied in and the bowel 
wrapped in gauze. Nine days after operation 
the redundant bowel is divided close to the skin 
level after it has been constricted for five 
minutes upon a rectal tube by a tonsil snare. 
The end soon retracts within the anus. At this 
time the patient can usuallj'' demonstrate 
voluntary contraction of the perineal muscles 
and constriction of the anus. In 1 50 cases this 

American Journal 0/ Surgery 



Babcock — Fecal Incontinence 


201 


operation has not been followed by anal 
prolapse, mucus protrusion or perineal hernia. 
The patient should remain under observation 
for several months for correction of any tend- 
ency to stricture formation and for direction 
as to bowel control. This operation exposes and 
enables a reseetion of involved levators, the 
prostate gland or vagina. The control obtained 
is usually adequate for solid or semi-solid 
intestinal contents. 

Technic for a Carcinoma on the Anterior Wall 
of the Rectum, Attached Anteriorly. After the 
preliminary transabdominal liberation of the 
upper rectum, sigmoid and any attached in- 
vaded structures a curved transverse incision 
is made centering 3 cm. in front of the anus. 
The terminal rectum is exposed and divided 
just above the sphincters, the end grasped in 
hemostats and widely liberated with any 
infiltrated attached portion of vagina or 
prostate and withdrawn through the perineal 
wound wrapped temporarily in a towel and 
laid over the pubis. The jaws of a Payr clamp 
are passed through the dilated anus into the 
pelvis and clamped across the liberated sigmoid 
to whicT an adjacent, more distal clamp is 
applied and the sigmoid is divided between the 
clamps. The proximal end of the sigmoid ma}’’ 
be withdrawn by its clamp through the anus 
so as to project 7 cm. or more. The vagina, if 
resected, is closed from below with one or more 
rows of interrupted wire sutures not pene- 
trating the mucosa. The transversus perinei 
and anterior raphe and skin are accurately 
united with buried and superficial interrupted 
No. 32 and 35 wire sutures and a rectal tube is 
tied in the protruding sigmoid. Pelvic drainage 
is accomplished by a sump drain previously 
Introduced through the abdominal wall to the 
bottom of the pelvis. To prevent strangulation 
of the withdravm sigmoid the sphincters may 
be stretched or incised. On the ninth post- 
operative day the protruding sigmoid is 
amputated as previously described. This type 
of operation is adapted for the more radical 
resections of the anterior pelvic floor. 

Withdrawal of the liberated rectum and lower 
sigmoid through the denuded, stretched sphinc- 
ters (H. E. Bacon) is similar to the Whitehead 
operation. The perineal skin is retracted at four 
cardinal points by Pennington clamps, the anal 
skin divided along the lower margins of the 
external sphincters with a posterior midline 
e.\tension through the skin for 5 cm., the 

January, /950 


sphincters denuded with fine scissors and the 
mucocutaneous lining clamped or ligated for 
traction. Aided by deep lateral retractors the 
rectum is liberated, the levators are divided 
and the rectum and lower sigmoid are with- 
drawn, resected a distance from the skin and a 
rectal tube tied in. A curved, perforated drain 
is introduced posteriorly along the sacrum for 
forty-eight hours and the adjacent wound is 
sutured. A week later the redundant bowel is 
resected and its edges tacked by fine catgut 
sutures to the edge of the anus. Patients with- 
out complication after anj"- of these pull- 
through operations usually leave the hospital 
on the eleventh or twelfth postoperative day. 

After any of these methods the patient 
retains a degree of voluntary sphincter and 
levator ani control which improves with com- 
plete healing, especially after the patient learns 
to adjust his diet and evacuant measures to his 
new condition. A few of the patients, however, 
have satisfactory control for liquids but, 
except during periods of watery diarrhea, most 
of them establish regular bowel habits with or 
without regulating enema or saline laxative 
taken every two to five days and are able to go 
without a protective pad. 

After reconstructive operations for fistula-in- 
ano or abdominoperineal proctosigmoidectomy 
a small percentage of the patients requests the 
additional improvement to be gained b}'^ 
anoplasty. In this operation the writer has used 
a wide U- or V-shaped cutaneous flap formed 
on the side of the anus having the scar and 
defect in the sphincters. The flap and scar are 
elevated by sharp dissection with a layer of 
subcutaneous fascia to provide vascularity. 
The ends of the divided e.xternal sphincters are 
located, covered by fibrous scar tissue. This is 
not completely excised as it holds sutures better 
than the denuded soft muscle. The ends are 
freed and united with interrupted No. 32 alloy 
wire sutures tied in a square knot opposite the 
mucosa and the wire ends are cut very close 
to the knot. The adjacent subcutaneous tissues 
are also united, reinforcing the sphincter and 
deepening the external • anal cone. The skin 
flap is so sutured to the adjacent skin that the 
U- or V-shaped incision is converted into a 
Y-shaped scar. To reduce tissue reactions only 
stainless wire sutures and ligatures are used 
in the wound. 

A more difficult problem concerns patients 
who desire to retain the anal opening and have 



202 


Babcock — Fecal Incontinence 


had the entire colon removed as for a papillary 
or ulcerative colitis. If an abdominal end-to-end 
anastomosis can be made above competent 
sphincters, by back pressure the terminal ileum 
may gradually dilate and develop a storage 
capacity with satisfactory results. Hov'ever, if 
it has been necessary to remove the anal lining 
or if the sphincters have been stretched, 
divided, or for other reason permits leakage of 
liquid ileac contents, the skin irritation pro- 
duced usually becomes unbearable. By leaving 
10 cm. of ileum protruding be3mnd the anus at 
the time of operation in any questionable case 
the ileal contents may be diverted from the 
perineum into a receptacle during the healing 
period and a delay obtained for the develop- 
ment of dilation and storage capacity in the 
lower ileum. Especially important is the fact 
that the competency of the sphincter may be 
determining and, if incomplete for liquids, a 


sphincter-tightening operation may be done 
and the result established before the projecting 
portion of ileuni is amputated. 

SUMMARY 

1. A method is described for the radical one- 
stage aseptic resection of chronic fistula-in-ano 
with primary closure and improved anal 
control. 

2. Assuming the abdominal phase of ab- 
dominoperineal resection for carcinoma of the 
rectum is well understood, several technics for 
the perineal part of the operation show that 
provided the anal area has not been invaded, 
the operation usually may be made sufTicientb' 
radical without loss of sphincter action. 

REFERENCES 

I. Babcock, W'. W. The immediate sterilization and 
closure of chronic infected wounds. J. A. M. A., 
72: 1459, igig. 




American Journal 0/ Surgery 



PATHOGENESIS AND TREATMENT OF EXTENSIVE 
ATYPICAL ANORECTAL FISTULAS 


R. V. Gorsch, m.d. and George L. Becker, m.d. 
New York, New York Paterson, Neiu Jersey 


A PPROXIMATELY 90 per cent of ano- 
rectal fistulas result from infectious 
processes arising in the anal canal. 
They may be clinically classified and are gen- 
erally demonstrable as complete or incomplete. 
Often fistulas are successfully treated by simple 
surgical procedures without residual anal incon- 
tinence. The terms anorectal and anal as ap- 
plied to the unsatisfactory classification of 
fistulas implies that these fistulas, whether 
complete or incomplete, have or have had a 
connection with the bowel. The initial infecti- 
ous process usually originating in the anal 
crypt is called “cryptitis.” When the internal 
opening cannot be definitely established in 
relation to the anorectal muscle ring, such 
classification is unreliable and may even be 
misleading. 

An appreciable number of so-called ano- 
rectal fistulas have an atypical pathogenesis; 
the primary infectious focus is not of cryptic 
origin and the fistulous tracts often have ex- 
tensive and unsuspected ramifications. Even 
though an anal or rectal opening may be 
demonstrable, it does not necessarily follow 
that the perianal or perirectal infectious process 
is or was of enteric origin. This conception has 
repeatedly confounded both the pathogenesis 
and the surgery. 

Extra-enteric suppurative foci from the 
urethra, seminal vesicles, adnexa, rectovaginal 
septum, endopelvic fascia, fetal rests, dermoids, 
bone or elsewhere may rupture into the anal 
canal or rectum and frequently result in blind 
fistulas or sinuses which may require extensive 
surgerj"^ for complete healing. These cases must 
be recognized as atypical and corrective surgery 
should be based on the correct evaluation of 
the original source of infection, the fistulous 
tracts, and their relation to the anorectal 
muscle ring. Most of these atypical cases have 
had previous surgery further complicating the 
disorder and treatment. 

1 he possibility of a tuberculous process must 
always be considered in at^ical fistulas re- 
quiring special consideration in management. 

January, ig^o 


The following cases of at3ipical fistulas pre- 
sent unusual and instructive features in their 
pathogenesis, diagnosis, surgical treatment and 
postoperative care. 

CASE REPORTS 

Case i. In 1936 a forty-one year old male 
experienced acute pain in the right lower quadrant. 
He consulted a local practitioner who referred him 
to a general surgeon with a diagnosis of acute 
appendicitis. On digital examination of the rectum 
an indefinite mass was felt and suspected of being 
a deep perirectal abscess; therefore, the appen- 
dectomy was deferred. The abscess was treated for 
one week with colonic irrigations and short-wave 
diathermy following which drainage was established 
by a puncture through the rectal wall. The patient’s 
convalescence was protracted but he recovered in 
four months. In 1941 because of a rectal discharge 
he consulted a proctologist who advised an oper- 
ation after making a diagnosis of a blind internal 
fistula. The patient refused. In 1943 he again 
experienced lower abdominal pain with a feeling of 
fullness in the rectum and elevation of temperature. 
A “fistula” operation was performed with incision 
and drainage of a high ischiorectal tract and 
abscess. Despite expert postoperative care the 
fistula recurred. The patient was operated upon 
again in 1944 for the recurrence with wide drainage' 
and further incision of the fistulous tract. The 
fistula again recurred. A course of deep x-ray 
therapy was given without benefit. He was advised 
to consult a good general surgeon who considered 
the appendix as a possible source of infection 
because of its proximity to the upper end of the 
tract. (Fig. i.) An - appendectomy was done but 
without relief. In June, 1948, his examination was 
as follows: A very long fistulous tract extended 
from an external opening in the right posterior anal 
skin through the visceral endopelvic fascia to just 
below the peritoneum of the right parareetal fossa. 
An offshoot from the main traet had entered the 
rectum just above the anorectal muscle ring. 

Digital examination of the rectum revealed a 
narrowed and scarred anal canal. The right rectal 
wall 2 inches above the sphincter was deeply 
scarred at the probable site of the original drainage 
stab wound. The stricture and scarring were 
sequelae of inadequate drainage. 

In proctoscopy the rectal mucosa was hyperemic 


203 



204 


Gorscli, Becker — Anorectal Fistulas 



Fig. I. Lipiodol injection of tract extending from 
perianal slan to chronic abscess cavity in right sub- 
peritoneal tissue directly below the appendix which 
contains traces of barium. Case i. 

and covered with a film of mucopus but was 
otherwise normal as was the sigmoid. The left 
ischiorectal fossa and superlevator tissues were 
normal and the patient’s general condition was 
excellent. 

Comment. Lower abdominal pain with onset 
of deep pelvic suppuration simulating appendi- 
citis or adnexal disease is not rare. It empha- 
sizes the value of a careful rectal examination 
and proctosigmoidoscopy before abdominal 
surgery. . ^ , 

The exact pathogenesis of the suppurative 
process in this case is obscure. Foreign body 
perforation of the sigmoid, a fetal rest in the 
endopelvic visceral fascia and a dermoid de- 
serve consideration. In the tuberculous a bony 
or retroperitoneal focus requires exclusion. The 
surgical approach to a deep pelvic abscess of 
this kind is of paramount importance. Drain- 
age through the rectal wall is entirely inade- 
quate, if it can be termed drainage at all. It 
provokes further fistulization. Regardless of 
whether or not the abscess has already ruptured 
into the rectum, complete external drainage 
insofar as is possible should be established at 
once and must include the primary focus if this 
can be found. Pelvic abscesses are gravitational 


abscesses and failure to drain the nidus of tlie 
suppurative process leads inevitably to ex- 
tensive sinus formation or secondary fistuliza- 
tion as occurred in this case which is now be- 
yond surgical or any other method of treatment. 


Case ii. On June 25, 1946, following an 
eighteen-hour labor a twenty-seven year old female 



Fig. 2. A, perineorectal fistula, internal opening below 
the anorectal muscle ring; b, pelvic abscess cavity and 
tract extending through the ischiorectal fossa to the 
perianal skin; the internal opening at the level of the 
anorectal muscle ring anteriorly; c, a small sub- 
cutaneous extension from the main tract. Case ii. 

delivered a normal child, with an assistive cpisi- 
otomy and immediate deep perineorrhaphy. Ten 
days later it was noted that she had developed a 
perineorectal fistula. She was referred to the New 
York Polyclinic Hospital for care. Her previous 
history was negative. Examination in October, 
1948, showed a perineorectal fistula with its 
external opening in the midline of the anterior anal 
wall at the level of the perineum and its internal 
opening in the midline of the anterior anal wall 
at the level of the deep external sphincter. On the 
left side i inch from the anus was another opening 
of a fistulous tract which extended to an abscessed 
cavity just above the pubococcygeus fibers at the 
levator ani muscle and w'hich occupied the anterior 
aspect of the deep pelvic space. The abscessed 
cavity is roughly 3 by 5 by 3 cm. An additional 
fistulous tract was disclosed during the operation 
and extended from this cavity into the rectum just 
above the deep external sphincter muscle. A minor 
subcutaneous tract extended anteriorly for about 
I inch into the left perivulval tissues. (Fig. 2.) 
Digital and vaginal examinations were negative 
except for confirmation of the cavity and tract al- 
ready described. ProctosigmoidoscopjMvas negative. 

The patient was operated upon by one of us 
(R. V. G.) in November, 1948. The surgical 
approach to this multiple fistulization was con- 
troversial. The question of anal continence was 

American Journal oj Surgery 



Gorsch, Becker — Anorectal Fistulas 


205 


important since any surgical procedure to be 
successful entailed division of the anorectal 
musculature at the level of the anorectal muscle 
ring. Due .consideration was given to the gyneco- 
logic versus the proctologic approach. The following 
procedure was finally performed: The perineorectal 
fistula was setonized with No. 32 steel alloy wire. 
The fistulous tract and abscessed cavity on the left 
side was widely opened and saucerized. Inspection 
of the abscessed cavity disclosed an offshoot from 
the main tract entering the rectum just lateral to 
and above the internal opening of the perineorectal 
tract. This was also setonized with wire. The 
ischiorectal incision was subsequently guttered well 
back beyond the gluteus maximus muscle. The 
small anterior subcutaneous tract was unroofed 
becoming continuous with a main, large saucerized 
wound. 

As healing progressed, both wire setons were 
gradually pulled through the musculature; the 
higher seton was removed after reaching the 
internal opening of the perineorectal tract. Finally 
all three divisions of the external sphincter were 
necessarily divided. 

Due to the deep and extensive ischiorectal wound 
there was considerable separation of the sphincter 
musculature despite the use of wire setons. . 

Healing was complete in six weeks. Anal con- 
tinence was slightly impaired but considered very 
good in view of the double fistulization and the 
original damaged perineum. There is a slight 
residual prolapse of the rectal mucosa which will 
require excision. 

Comment. Fistulization following postpar- 
tem perineorrhaphy appears to be more fre- 
quent than reported. Due to the laxity of the 
parturient canal inclusion of the rectal wall or 
its penetration in the perineal repair can in- 
advertently and readily occur and is probably 
done more often than is suspected. 

The proper surgical approach in this type of 
case is very important. We believe the vaginal 
approach in this case would necessarily have 
compromised adequate drainage, a sine qua non 
to a successful result. Stage procedures with 
wire setons were indicated and assisted in re- 
taining anal continence. Precise localization of 
the tracts in relation to the anorectal muscle 
ring as well as to the pubococcygeal fibers of 
the levator ani anteriorly were essential to a 
successful surgical result in this case as well as 
to the proper evaluation of subsequent anal 
continence. 

Case in. A well developed thirty year old male 
w^ operated upon for internal hemorrhoids in the 
military service in May, 1945. Following this he 
had a purulent rectal discharge for several months. 

January, ig^o 


The patient was operated upon again with a 
diagnosis of fissure-in-ano during October, 1945, 
with an apparently successful result. However, in 
October, 1947, he complained of pain over the 
coccyx, elevation of temperature and a purulent 
discharge from the rectum. Examination at this 



Fig. 3. The fistulous tract extends from the posterior 
midline of the anal canal at the level of the pubo- 
rectalis muscle, to a subcoccygeal abscess cavity 
with an extension into the left ischiorectal fossa. 
Case hi. 

time revealed a posterior fistulous tract extending 
from the puborectalis level of the anal canal to the 
deep posterior triangular space and extending 
to the coccy.x. Digital examination of the rectum 
precluded satisfactory delineation of the tracts 
because of the excessive posterior scarring. Procto- 
sigmoidoscopy was negative as was x-ray of the 
coccyx and sacrum. 

In October, 1947, he was operated upon for the 
third time. An incision was made from the opening 
^ in the anal canal directly posteriorly for a distance 
of 4 inches, dividing all the intervening tissue 
including the sphineter muscle down to the pubo- 
rectalis. The incision was carried down to and 
around the coccyx where a small abscess was 
encountered. Rubber tissue drains were inserted 
into the tracts after curettage and phenolization. 
A drain was also inserted into the main fistulous 
tract beneath the tip of the coccyx. Despite careful 
postoperative care the fistula recurred. 

In February, 1948, examination and injection of 
lipiodol revealed extensions of the fistulous traets to 
the left isehiorectal fossa and below the coecyx. 
(Fig. 3A and b.) X-ray of the coccyx and sacrum 
rvere again negative as was proctosigmoidoscopy. 

In February, 1948, under spinal anesthesia the 
patient was operated upon for the fourth time by 
one of us (R. V. G.). The entire posterior tract was 
incised from the internal opening at the level of the 
puborectalis to the lateral extensions of the tracts 



2o6 


Gorsch, Becker — Anorectal Fistulas 


which were carefully followed into both ischiorectal 
fossae, particularly the left. The coccyx required 
excision for complete drainage. The wound on the 
left side U’as guttered posteriorly beyond the 
gluteus maximus muscle which was partly incised. 
This posterior extension was essential to secure 



Fig. 4. Fistulous tract extends backward from the 
posterior midline of the anal canal at the pubo- 
rectalis level to the coccyx and then laterally and 
anteriorly into the deeper portion of the right ischio- 
rectal fossa. Case iv. 

efilcient saucerized drainage for botli ischiorectal 
wounds. The entire external sphineter muscle was 
of necessity divided. Some degree of ultimate 
incontinence was anticipated. The wounds were 
carefully observed for bridging, not packed, but 
healing was protracted because of the previous 
extensive scarring. Anal continence was good. 

Comment. The surgery of hemorrhoids and 
fissure may be of etiologic significance in 
anorectal fistulization. Careful exclusion of all 
associated disorders should be made before 
proctologic surgery, especially in those patients 
complaining of purulent rectal discharge. 
Stereoscopic lipiodal delineation was helpful in 
disclosing the extensions of the tract below the 
coccyx. Removal of the coccyx and posterior 
guttering through the gluteus maximus muscle 
was essential to adequate saucerized drainage 
and subsequent healing. 

Case iv. A twenty-five year old male in good 
physical condition was operated upon for fissure- 
in-ano in July, 1944. The following July a perirectal 
abscess developed which was incised and drained 
resulting in a fistula. In August, 1945, the patient 
was operated upon for the fistula and a pilonidal 
cyst. The fistula recurred. During 1 946 he received 
an infinite number of treatments with silver nitrate 
applications and during this time had several 
abscesses which broke spontaneously into the 


rectum. However, his fistula persisted despite the 
jirotractcd cauterization. 

He consulted several proctologists and general 
surgeons who believed that the fistula was incurable 
and further surgery would lead to incontinence. 

In September, 1947, examination disclosed a 
large posterior scar e.xtending from the postanal 
verge to the lower end of the sacrum. At the level 
of the puborectalis muscle in the anal canal there 
was a fistulous opening, the tract of which ex- 
tended posteriorly below the levator shelf and 
laterally into the depths of the right ischiorectal 
fossa. (Fig. 4.) 

In October, 1947, another operation was per- 
formed by one of us (R. V. G.) while the patient 
was under spinal anesthesia. The entire fistulous 
tract extending into the right ischiorectal fossa was 
incised; in order to obtain saucerized drainage it 
was necessary to extend the wound posteriorly 
beyond the sacrum incising the gluteus maximus 
muscle. During this saucerization the inferior 
hemorrhoidal stalk was cut and tied causing a 
subsequent area of anesthesia in the perianal skin 
on the right side. The external sphincter was 
setonized with No. 30 steel alloy suture wire. This 
wire was successively seesawed through the exter- 
nal sphincter divisions when the granulations 
reached its level. The wire was finally cut out with 
local infiltration anesthesia. The large wound 
granulated very rapidly considering its depth. 
Final healing was complete in about eight weeks. 
Recently the patient wrote, “1 do have slight 
incontinence which isn’t at all troublesome and 
one side of my buttock is still numb but e’est la 
guerre.” 

Comment. A blind fistula of this kind is 
especially prone to form abscesses with further 
extension of the tracts which decrease the 
chance of ultimate cure. The amount of puru- 
lent drainage in this patient w'as sometimes 
profuse indicating a large, chronic, abscessed 
cavity. Despite the chances of incontinence 
these fistulas should be operated upon; if neces- 
sary, continence may be restored by subsequent 
surgery. Wire setonization of the entire ex- 
ternal sphincter muscle was assistive in main- 
taining minimum separation of the sphincter 
ends and preserving anal continence. 

The decision as to radical surgery in this 
type of case should be made by a qualified 
proctologist. A condemnation to incurability 
produces a permanent psychic insult. 

Case v. A fifty-one year old male was initially 
treated in 1937 for hemorrhoids, receiving biweekly 
injections for about six weeks. In 1939 he com- 
plained of pressure in his rectum with some 
difficulty on urination. Examination by a local 

American Journal of Surgery 



Gorsch, Becker — ^Anorectal Fistulas 


207 


proctologist revealed a blind external ^interior anal 
fistula. The patient was operated upon in the 
practitioner’s office under local anesthesia. Follow- 
ing the operation there was considerable and 
repeated hemorrhage finally controlled in the 
patient’s home. The fistula recurred but despite an 
intermittent purulent rectal discharge the patient 
did not desire further surgical attention. It was not 
until 1947, eight years later, that he came to one 
of us (G. L. B.) with a complaint of marked 
urinary difficulty and a persistent rectal discharge. 

Examination at this time revealed the following 
atypical multiple fistulas: There were two fistulous 
openings in the perianal skin, one in the- left an- 
terior quadrant at one o’clock and another in the 
right anterior quadrant at ten o’clock (Fig. 5.) 

On digital examination the left fistulous tract 
extended directly into the anal canal at one o’clock 
to the level of the intermuscular septum. The right 
fistulous tract, however, extended into a fairly 
large, abscessed cavity in the right ischiorectal 
fossa from which there was a secondary extension 
upward parallel to the rectal wall for about 8 cm. 
No internal opening was found for this tract. The 
pus expressed from the tract was characteristic of 
tuberculosis. 

Anoscopic examination showed a dull, grayish, 
hyperplastic and linear scarred mucosa with small 
granulomatous excrescences suspicious of tuber- 
culosis. Proctosigmoidoscopy was negative as were 
urine and blood studies. X-ray report of the chest 
showed chronic pulmonary tuberculosis of the left 
upper lobe. The question of activity had to be 
determined clinically by x-ray follow-up. 

Stereoscopic radiographic injection of the right 
abscessed cavity and tract revealed a sinus collec- 
tion of media measuring about 2 inches in the 
region of the anus. No bone abnormality was noted. 

The patient was operated upon under sacro- 
caudal anesthesia of the third, fourth and fifth 
foramens by one of us (G. L. B.). Examination 
under anesthesia disclosed the left tract as a 
direct, complete, low level, anal fistula without 
cavitation. The right tract, however, extended 
laterally around the anal canal to an internal open- 
ing in the midline posteriorly, with an extension 
into a large cavity in the right ischiorectal fossa 
as already mentioned. Methylene blue injected 
into this tract readily appeared at the posterior 
opening in the rectum. 

The left direct tract was incised through the 
subcutaneous external sphincter muscle. A probe 
was then passed into the right tract and the entire 
intervening tissue extending well up into the ischio- 
rectal fossa to the level of the levator ani muscle 
was widely opened and the incision carried back 
to beyond the tip of the coccyx. A considerable 
amount of chronic tuberculous granulation tissue 
wp excised and the outer wall of the cavity seared 
with the actual cautery. It was considered inadvis- 

January, ig^o 


able to incise the intervening muscle in the posterior 
commissure at this time; therefore, a wire seton 
was placed through the remaining portion of the 
tract and tied externally. The entire wound was 
loosely packed with oxycel gauze after tying active 
bleeders. Vaseline gauze was placed in the wound 
with a dry dressing over all. 



Fig. 5. Multiple fistulas; a, direct complete low anal 
fistula, external opening in right anterior quadrant of 
perianal skin at ten o’clock, internal opening directly 
opposite external opening; midline anteriorly is twelve 
o’clock; B, large thick walled abscess cavity with tract 
extending to internal opening in perianal skin at one 
o’clock. 

During the healing, which was protracted, the 
wire seton was periodically seesawed through the 
intervening sphincter muscle and was finally re- 
moved under local infiltration anesthesia three 
weeks following operation. Secondary revision of 
the large wound was necessary to maintain unob- 
structed drainage. Anal continence was surprisingly 
good considering the loss of a large part of the 
subcutaneous and superficialis portions of the 
external sphincter on the right side. A small 
residual submucous sinus persisted for several 
months postoperatively but has apparently closed. 

SUMMARY AND CONCLUSIONS 

Five cases of atypical anorectal fistulas have 
been described to emphasize the following 
points: 

1. In the history detailed operative reports 
are important for a proper evaluation of the 
pathogenic factors and treatment. 

2. In the pathogenesis of anorectal fistula an 
extra-enteric focus requires careful considera- 
tion; it is commonly overlooked. An opening 
found in the rectal wall or anal canal is not 
necessarily a primary fistulous opening and 
the surgery done on this basis may be errone- 
ous and unsuccessful. The emphasis on crypti- 
tis and the present unsatisfactory classification 
of anorectal fistulas have tended to confuse the 


2o8 


Gorsch, Becker — Anorectal Fistulas 


pathogenesis as well as the surgical treatment 
of such fistulas. Fistulas following hemorrhoid 
and fissure surgery are usually of the so-called 
blind variety. They are sometimes difficult to 
outline without stereoscopic radiographs. 

3. Rectal suppuration and fistulization fol- 
lowing immediate perineorrhaphy is more 
common than suspected. Fistulas in these 
cases usually involve the so-called supralevator 
spaces since the rectal penetration is at or 
above the pubococcj^geal level. Rectovaginal 
and rectoperineal fistulization are readilj’ 
explained on the same basis. The anterior 
location of these fistulas compromises the 
anal continence. 

4. In determining the extent of fistulas the 
injection of topogesine, which can be colored if 
desired, and stereoscopic lipiodol injections 
together with careful probing of the tracts are 
very informative if properly performed and 
evaluated. These measures are essential in 
tracts extending to bone, foreign bodies, sus- 
pected tumors, dermoids, fetal rests, etc. 

5. In surgery of perirectal abscesses drainage 
through the rectal wall deserves the severest 
condemnation. Spontaneous rupture into the 
rectum is not surgical drainage; in fact, it 
indicates external drainage to avoid chronic 
sinus formation and secondary suppuration as 
well as to conserve the reparati\"e capacity of 
the rectal wall. The careful tracing of each and 
every tract to its termination followed by ade- 
quately guttered and saucerized drainage is 


nccessar\'^ for complete healing in these ex- 
tensive fistulas. This may entail incision 
through the gluteal muscles, excision of the 
cocc^Ti: or lower sacrum and even division of 
the triangular ligament anteriorl}^ To com- 
promise adequate drainage because of the 
danger of incontinence is to invite recurrence. 

6. Setonization of the musculature is prefer- 
ablj’^ done with suture wire No. 40. Tjdng knots 
in the wire permits more rapid cutting through 
the musculature. 

7. In postoperative care bridging of granula- 
tion tissue, pocketing and bone infections are 
the more important deterrents to sound heal- 
ing. Secondary involvement of the coccjoc or 
sacrum requires immediate surgical attention. 

8. Anorectal tuberculosis with fistulization 
is invariably a secondary process which is in- 
herently recurrent not only in its local involve- 
ment but also from the distant focus, usually’ 
pulmonary, as well. A careful evaluation of 
these factors is necessary to successful surgery 
with passable anal continence. In tubercular 
fistulas recurrence is common and repeated 
surgery maj" result in anal incontinence which 
is far more distressing than the fistula. Reports 
on streptomycin in tuberculous fistulas are 
encouraging. 

9. Maintaining an adequate physiologic 
environment for the growth of sound granula- 
tion tissue by continuous free drainage is far 
more important than the use of any granulation 
stimulant. 




American Journal oj Surgery 



ULCERATIVE COLITIS— THE PANIC DISEASE 


Simon B. Kleiner, m.d. 
New Haven, Connecticut 


M y interest in the relation of avitamino- 
sis to chronic idiopathic ulcerative 
colitis was first stimulated by a very 
close friendship with the late Professor Lafa- 
yette B. Mendel. I was particularly interested 
in a reprint he gave me of a paper which he 
published with Underhill in 1928.^ Colored 
illustrations of the effect of vitamin deficiency 
on the dog’s colon and descriptions of the 
bloody diarrhea in these cases closely re- 
sembled the picture of ulcerative colitis in the 
human so much that it seemed wise to try a 
new approach in the management of this 
disease. Consequently, since 1930 I have been 
using vitamin therapy combined with other 
forms of treatment and have achieved the 
results described herein. 

A volume could be filled with the various 
theories regarding the etiology of ulcerative 
colitis. My personal opinion based on the work 
of Andresen,^ Mendel and Underhill,* Brown 
and his associates,® and others as well as from 
observations on my patients is that the factors 
responsible for this condition are a combination 
of allergy, avitaminosis and psychosomatic dis- 
turbance plus superimposed anaerobic infection. 

I have come to the conclusion (which may 
or may not be right) that the sequence of events 
resulting in acute and/or chronic idiopathic 
ulcerative colitis is as follows: (i) allergj'^ and 
psychic disturbances causing diarrhea, (2) 
avitaminosis causing lesions of the submucosa 
and (3) ulceration and infection of these lesions. 

These conditions may occur in sequence or 
the onset may be so insidious that the whole 
series of events is precipitated at one time. 
Nevertheless, management of the patient with 
ulcerative colitis is most successful if it is based 
on the hypothetic and etiologlc factors which 
I have described. 

In assuming that the diarrhea is due to the 
combined effect of allergy and psychic dis- 
turbance let us first consider the type of diar- 
rhea encountered in this syndrome. It is not a 
true diarrhea but usually a spurious type 
consisting of frequent excretion of blood and 
pus and accompanied with severe cramps. Very 

Januan/', ig$o 


little fecal matter is passed; in fact, Mackle'* 
has reported hypomotility of the transverse 
colon in 50 per cent of a series of cases in which 
the patients had frequent evacuations, cramps 
and tenesmus. In these patients (all having 
ulcerative colitis) gastrointestinal x-ray series 
showed barium in the transverse colon up to 
ninety-six hours in some cases. I am wondering 
whether the blood or pus has a toxic effect on 
the mucosa of the sigmoid and rectum greatly 
stimulating peristalsis and causing the severe 
cramps. We have all noted that in postopera- 
tive bleeding the patients have the same urge 
to defecate that they have in ulcerative colitis. 
This question should be investigated further 
and would certainly make a nice subject for 
research. 

Whatever the cause diarrhea is probably 
responsible for a considerable loss of vitamins 
from the body. Because we consider diarrhea 
an allergic manifestation, treatment is started 
by cleaning out the bowel. This in itself is quite 
a task as it is most difficult to convince the 
family doctor as well as the patient that a good 
dose of the old standby, castor oil, is the best 
way to start treatment even in severe cases. 
Strange as it may seem the administration of 
castor oil often results in improvement of the 
patient at once. This procedure also enables 
one to pass a sigmoidoscope and determine the 
extent of the lesions. The patient is put on a 
regular diet, the only restriction being the 
certain food to which he may be allergic. Here 
again one runs up against opposition. Most 
doctors whom the patient has consulted have 
probably given him a so-called low residue diet, 
the type that results in hard, small and dry 
stools because of constipation. The doctor, 
family and patient alike throw up their hands 
in horror when one insists upon a normal diet 
excluding only one food at a time; the first is 
usually milk. If there is no improvement after 
a few weeks on the usual diet with the excep- 
tion of milk, the patient is again allowed milk 
but some other food such as wheat, potatoes, 
citrus fruits, chocolate or something else is 



210 


Kleiner — Ulcerative Colitis 


withdrawn; or, the patient can be put on the 
usual elimination diets used to determine food 
allergies. I do not like these diets, personally, 
as again these have an effect on the psyche. 

There are at least three benefits to be derived 
from the regular diet, (i) Assuming that there 
is a psychic factor as a basis for the disease the 
effect of the patient’s being able to sit down 
and eat essentially the same food as the rest 
of his family and friends is very helpful to his 
morale. (2) If ulcerative colitis is a vitamin 
deficiency disease, vegetables and fruits lose 
vitamins when pureed. Consequently, a low 
residue diet of pureed food decreases vitamin 
intake. (3) A regular diet will help to maintain 
nutrition and body weight. This is most im- 
portant as we all know that patients with 
ulcerative colitis do much better when well 
nourished and keeping up the body weight is 
an important consideration. On the other hand, 
the author has never seen any ill effects from 
changing to this type of diet; in fact, this simple 
dietary trick (i.e., switching from low residue 
to regular diet) will often cause marked im- 
provements in the symptoms at once. Malbin’’ 
demonstrated in the last war that coarse diet 
could be given typhoid patients without bad 
effects. Felsen® also says that fear of using 
coarse diets in ulcerative colitis is largely un- 
founded providing the food is well masticated. 

As mentioned before Brown and his col- 
leagues® are responsible for considering psychic 
disturbances as a definite cause of ulcerative 
colitis. This theory is borne out clinically to a 
certain extent and a careful investigation of 
all possible psychic disturbances followed by 
their correction, if possible, is most valuable. 
Practically every patient I have seen has shown 
some such psychic factor, either sexual, 
financial, domestic or other trouble. Often the 
patient does not realize the presence of this 
disturbance until it is brought out by careful 
questioning and then attempts can be made 
to correct the difficulty. In addition an earnest 
attempt should be made to keep the patient at 
his normal occupation and other activities as 
this too is important from a psychologic 
standpoint. 

As a working hypothesis let us consider that 
the patient has developed a lack of vitamins 
(especially the B complex) due to low intake 
in the diet as has been customarily prescribed 
and to possible abnormal excretion of these 
important compounds. We must also realize 


in this respect that each individual requires 
different amounts of vitamin for maintenance 
of normal health and that in different persons 
avitaminosis may show a different sympto- 
matology. However, considering our specific 
problem, it must be met bj'^ giving adequate 
doses of either B complex or thiamine chloride. 
I like to start with 100 mg. doses of thiamine 
chloride intramuscularly daily and, in addition, 
either capsules or tablets of thiamine or B com- 
plex three times a day. 

Saving the juices which are obtained when 
vegetables are cooked and drinking the juices is 
also a good and inexpensive way to provide 
added vitamins at home. If the patient is in the 
hospital, the vitamins may be added to trans- 
fusions or infusions when these are required. 
As the patient imporves, hypodermic ad- 
ministrations can be reduced to weekly or 
even monthly injections. One should insist on 
seeing the patient at least once a month. I 
find that eventually they fail to appear unless 
some form of treatment is given. Consequently 
an injection of vitamin or insufflation of bis- 
muth subgallate similar to the technic de- 
scribed by Soper® at each visit are helpful in 
keeping the patient from “stra3'ing from the 
fold” as well as being of possible therapeutic 
value. 

Let us consider the question of infection in 
these patients. Instead of treating the discharge 
of pus and blood as coming from ulcers due to 
primary bloodstream infection we choose to 
look upon them as ulcers due to secondary' 
invasion of the submucosal lesions described 
by Mendel and Underhill.' Consequent!}", if 
the case is severe and the passage of sero- 
sanguineous matter is profuse or if the patient 
is showing signs of absorption as manifested 
by arthritis, high irrigations of solutions of 
oxidizing agents may be very valuable. The 
reason for using oxidizing solutions such as 
potassium permanganate or suspension of zinc 
peroxide is that it has been demonstrated by 
Dack^ that the invading organisms are anae- 
robic. These irrigations will often clear up the 
discharge rapidly and reduce the temperature. 

The following results are based on treatment 
of fifty-one patients. My whole series taken 
exclusively from private practice consisted of 
seventy-six patients. However, about one- 
third of these patients (twenty-five) were seen 
only onee in consultation and are not included 
in tabulating the results of the effects of the 

American Journal of Surgery 



Kleiner — Ulcerative Colitis 


21 I 


regimen previously described. Moreover, al- 
though some of the fifty-one patients were seen 
only for a few months, it was thought proper 
to include them even though there might not 
have been any improvement; in fact, if only 
the long term cases had been included, a 
slightly higher percentage of improved cases 
would probably have been shown. It may be 
argued that the cases I have seen were only 
the mild ones but in a series of fifty-one cases 
it is believed that some would have become 
severe. It is believed, and with some satisfac- 
tion, that by following the methods I have 
outlined we have not allowed the disease to 
become severe. A definite attempt has been 
made to keep the patients at their normal work 
and activities for psycholdgic reasons. As 
many as possible are treated as office cases; if 
they become bad enough for hospitalization, 
this is advisable by all means but treatment at 
home is most unsatisfactory and should not be 
attempted. 

In proper hands surgery (colectomy not 
ileostomy or colostomy) may prove efficacious 
but I am yet to be convinced of its value and 
advisability if the lumen of the colon is not 
appreciably constricted. 

The age incidence in my seventy-six cases 
was approximately the same as in the usual 
series. The youngest patient was ten years old 
and the oldest seventy-seven. Sex incidence 
(45 per cent male and 55 per cent female) was 
not unusual. 

Of the fifty-one patients treated the longest 
time that a patient had been followed up was 
almost eighteen years; and although this lady 
strayed to other physicians and mush diets 
occasionally, she came back to me when she 
got into trouble and we got her straightened 
out. The shortest length of time that a patient 
of this series was treated was two months. She 
did not improve and a consulting physician 
advised a colectomy which resulted in death. 
As a matter of fact, the only deaths in our 
series, three in number, were the results of 
colectomies. This leads me to make the state- 
ment that chronic idiopathic ulcerative colitis 
although a fearsome disease does not usually' 
result in death. 

The three cases mentioned before show a 
mortality of approximately 5.8 per cent in the 
series of fifty-one patients. According to my 
records the disease in eighteen (35.3 per cent) 
of the patients was arrested; that is, when the 

January, ig^o 


patients were last seen, no lesions could be 
found on sigmoidoscopic examination and they 
were symptom-free. Twenty-seven (53 per 
cent) additional patients were improved while 
three (5.8 per cent) were unimproved when I 
last saw them. Of the three unimproved two 
had continued their regular occupations making 
a total of forty-seven or 92 per cent who con- 
tinued their normal occupations. 

One cannot call a patient with ulcerative 
colitis cured but can only hope that it will not 
recur. Any indiscretion on the part of the 
patient may cause trouble, such as in the case 
of the patient who was allergic to citrus fruit 
who ate prunes flavored with lemon. I have 
found that alcohol, even in the form of tonics 
or alcoholic preparations of vitamins, is harm- 
ful. Ordinary colds, influenza, etc., may start a 
recurrence. It is useless to enumerate the per- 
centage of recurrences or the time element as 
statistics vary from week to week. Suffice it to 
say that on the regimen as I have presented it 
the prognosis of a useful life for the ulcerative 
colitis patient is not nearly as bad as it has been 
painted. 

Many different forms of therapy have been 
tried on _my patients in the course of years, 
namely, vaeeines made from autogenous cul- 
tures of Bargen’s organism, different types of 
irrigations, sulfa drugs, etc. Through the 
courtesy of Dr. Samuel Peck of New York 
cobra venom was tried on a few patients but 
was discontinued as the latter showed no im- 
provement. Naturally, until the cause of this 
disease is found, we shall have to grope for a 
cure; until that time the procedure as deseribed 
before has proven quite satisfactory. 

I have called this the panic disease for the 
diarrhea and cramps with the accompanying 
bleeding truly strike panic in the heart of the 
doctor, patient and patient's family. Like 
panic, if it is not curbed, it becomes serious. 
By facing the matter sanely, reassuring the 
patient and using a eommon sense course of 
treatment, this panic disease can at least be 
alleviated. 

REFERENCES 

I* ^i^nERHiLL, P, P. and AtENDEC, L. B. A dietary 
deficiency canine disease-further experiments on 
the diseased condition in dogs described as 
pellagra-Iike by Chittenden and Underhill and 
possibly related to so-called black-tongue. Am. J. 
Physiol., 83: 585-633, 1928. 

2. Andresen, a. F. R. Allergic manisfestations in the 
colon. Tt. Am. Proct., Sec., pp. 227-241, 1939. 



212 


Kleiner — Ulcerative Colitis 


3. Bkown, W. T., Pkeu, P. W. and Sullivan, A. J. 6, Felsen, J. Bacillary Dysentery, Colitis and En- 

Ulcerative colitis and personality. Am. teritis. P. 42. Philadelphia, 1945. W. B. Saunders. 

95: 408-420, 1938. 7. Dack, G. M., Dragstedt, L. R. and Heinz, T. E. 

4. Mackie, T. T. The medical management of chronic Bacterium necrophorum in chronic ulcerative 

ulcerative colitis. J. A. M. A., iii: 2071-2075, colitis. J. A. M. A., 106: 7-10, 1936. 

1938. 8. Soper, H. W. Treatment of ulcerative colitis. 

5. Malbin, B. Typhoid fever occurring in immunized South. M. J., 29: 901-904, 1936. 

persons. J. A. M. A., 115: 33-36, 1940. 




American Journal oj Surgery 



GRANULOMATOUS RECTAL STRICTURE* 

CLINICAL RESPONSE TO DIETHYLSTILBESTROL 


F. George Rebell, m.d. and Fred E. Bradford, m.d. 
Los Angeles, Calijornia 


A S knowledge of lymphogranuloma vener- 
eum accumulates, the lack of a satis- 
factory non-surgical treatment for 
benign granulomatous rectal stricture becomes 
increasingly evident^ The consensus is that 
once a rectal stricture has developed, response 
to any form of treatment is indifferent.-’® 
Colostomy, the usual procedure of last resort, 
evades the main problem, namely, relief of the 
stricture. 

In 1942 Goldman"* reported the case of a 
woman in whom a rectal stricture, the sequel 
of Ij^mphogranuloma venereum, was greatly 
alleviated during pregnancy. To investigate 
this possibility we began to treat granulomatous 
rectal strictures of similar origin in both male 
and female patients with an oral estrogen, 
diethylstilbestrol. No prior record has been 
found of estrogenic therapy in men with this 
condition. The work of Seley, Vernick and 
Goldman® provided further impetus. 

The purpose of this study is to determine the 
value of diethylstilbestrol therapy on benign 
rectal strictures of a granulomatous nature. In 
the course of the investigation we formed a 
useful estimate of the average daily dosage and 
of the length of time the medication must be 
taken to produce results. 

One hundred fourteen cases of granuloma- 
tous rectal stricture were studied. In each 
patient the reaction to the Frei test using chick 
embryo antigen was positive. The patients were 
selected from the Proctologic Services of the 
Los Angeles County General Hospital and of 
the White Memorial Clinic, Los Angeles, 
California. 

For the purpose of comparison the patients 
are divided into two groups. Group i comprises 
ninety persons treated between 1938 and 1945 
by measures other than the administration of 
diethylstilbestrol and Group ii comprises 
twenty-four persons treated between 1946 and 
1949 with diethylstilbestrol therapy. 

Review of the ninety cases in which’dlethyl- 


stilbestrol was not employed showed disap- 
pointing results. Non-surgical methods were 
usuallj'^ questionable or transient in effect and 
often painful in application. Bouginage using 
Wales bougies, application of solidified carbon 
dioxide, irrigations of sulfanilic acid and the 
taking of oral sulfonamides were so ineffective 
that a permanent eolostomy was necessary to 
relieve actual or impending obstruction in 
approximately one-third of the cases. 

The group treated with diethylstilbestrol 
consisted of six men and eighteen women; 
twenty-two were negroes and two, one man and 
one woman, were white. Each had a granuloma- 
tous stricture of the rectum and in all the Frei 
test was unequivocally positive. The period of 
observation ranged from a few months to three 
years. 

Negro women in the child-bearing period 
were chiefly affected, most commonly between 
the ages of twenty-six and forty-five. Of the 
entire series of twenty-four patients the greatest 
number of strictures, 41.67 per cent, was found 
between the ages of thirty-one and forty. 
(Table i.) 

Symptoms. Symptoms followed the same 
pattern in nearly all cases and consisted of 
constant rectal discomfort with difficulty in 
evacuation which could be relieved only by 
laxatives or enemas. In some instances passage 
of blood and pus occurred and evacuations of 
small caliber were noted. Complicating lesions 
such as anal fistulas gave rise to characteristic 
findings. 

Types oj Lesions. Before the administration 
of diethylstilbestrol a careful examination was 
made with particular attention given to the 
extent and form of the stricture. A narrow ring 
with a longitudinal measurement arbitrarily 
set at 2.5 cm. or less was considered an annular 
type; and if the ring measured more than 2.5 
cm. in length, the stricture was designated as 
tubular. The terminology and measurements 
follow the precedent set by Bacon.® Careful 


From the Proctologic Service, Los Angela County General Hospital, and the Department of Proctology Colle^r, 

of Medical Evangelists, Los Angeles, Calif. 

January, ig^o 213 



214 


Rebel!, Bradford — Rectal Stricture 


estimation was made of the size of the stric- 
tured lumen. The distance of its distal edge 
from the anal margin in practically all cases was 
just above and on the mucosal side of the 
dentate line. 

An annular type of stricture was present in 
eighteen or 75 per cent; in two or 8.3 per cent 

Table i 

SEX, AGE, TVPE OF RECTAL STRICTURE AND 
COMPLICATIONS IN TWENTI'-FOUR PATIENTS 
WITH LYMPHOGRANULOMA VENEREUM 






Dis- 







tnnee 



Case 

Se\ 

Age 

Type 

from 

Anal 

Mar- 

Size 

fmm.) 

Complications 





gin 

(cm.) 



I 

F 

28 

c 

* 

7.5 

7 ot 

Rectovaginal fistula 

2 

F 

35 

annular 

4.0 

12.0 

None 

3 

F 

26 

* 

4.5 

8,0 

None 


F 

33 

annular 

4.0 

7. 5 

Fistula-in-ano 

5 

F 

34 

annular 


« 

None 

6 

F 

35 

annular 

4.0 

12.0 

None 

7 

F 

46 

annular 

4.0 

* 

None 

8 

F 

50 


5.0 

8.0 

None 

9 

F 

57 

annular 

4.0 

8.0 

Fistula-in-ano 

10 

F 

30 

tubular 

5.0 

7.5 

Urethral stricture 

II 

F 

28 

annular 

5.0 

7.5 

Fistula-in-ano 

12 

F 

42 

annular 

7.5 


Fistula-in-ano 

13 

F 

53 

annular 

6.3 

7 . 3 t 

Fistula-in-ano 

14 

F 

35 

annular 

4.0 

7-5 

Perianal abscess 

1$ 

F 

38 

annular 

5.0 

7.5 

Fistula-in-ano 

16 

F 

40 

tubular 

3-0 

7 . 3 t 

Permanent colostomy 

17 

F 

43 

annular 

3.0 

7.5 

Fistula-in-ano 

iS 

F 

44 

annular 

4.5 

10. 0 

Fistula-in-ano 

19 

M 

37 

annular 

3.5 

15.0 

None 

20 

M 

37 

« 

* 

« 

None 

2lX 

M 

48 

annular 

6.3 

7.5 

Fistula-in-ano 

22 

M 

42 

annular 

5-0 

7 . 3 t 

None 

23 

M 

46 

annular 

5.0 

7.5 

bistula-in-anoj 

24 

M 

39 

annular 

8.0 

7.5 

None 


* Information not recorded 
t Less than the figure indicated 
t Caucasians 

§ Developed subsequent to treatment 

the stricture was tubular. The type of stricture 
was not recorded in four. (Table i.) 

In seventeen or 70.8 per cent the distal edge 
of the stricture was located just above the 
dentate line 3 to 5 cm. from the anal mar- 
gin. Five strictures or 20.8 per cent were 
found from the 6.5 cm. to the 8 cm. level. In 
two the exact location of the stricture was not 
stated. The distal edges of the two tubular 
strictures were located at the 3 cm. and 5 cm. 
levels. 

In nine patients an anal fistula existed at the 
initial examination, in one a perianal abscess 
and in another a rectovaginal fistula indicating 
a high incidence of complications. An anal 
fistula developed in one patient subsequent to 
treatment. 


Before beginning treatment sixteen patients 
or 66.6 per cent presented strictures measuring 
8 mm. or less in diameter,® the majority ad- 
mitting only the tip of the index finger. In these 
passage of a standard size (18 mm.) sigmoido- 
scope through the strictured segment was 
obviously never successful. 

TREATMENT 

Oral diethylstilbestrol was chosen because of 
its ready availability, ease of administration 
and low cost. Dosage was from 3 to 15 mg. 
daily. The length of treatment depended on 
improvement in ph3’’sical findings. 

Fifteen of the patients received sulfonamides 
concurrentlj’- or alternately with the diethyl- 
stilbestrol medication. Sulfonamides appeared 
to have no direct beneficial effect on the rectal 
strictures. 

The unpleasant side effects of diethyl- 
stilbestrol were not severe and were controlled 
bj" adjusting the dosage or frequenej’^ of ad- 
ministration. Heavj’’ menstrual flow -noted in a 
few cases was overcome by temporarilj’- dis- 
continuing the medication. Nausea which 
developed in several instances early in the 
studj' was avoided either by using enteric- 
coated tablets or bj' giving the preparation 
with milk on retiring. In the male patients a 
moderate degree of mammary hiTjersensitive- 
ness was not annoying enough to warrant dis- 
continuing treatment. 

RESULTS 

Relief of rectal discomfort and easier passage 
of the stool within one to four weeks was 
recorded in all six men and in sixteen of the 
women or 91.25 per cent of the group given 
diethylstilbestrol. (Table ii.) Objective^, there 
was a decrease in rigidity of the stricture and a 
lessening of fixation in these patients. This 
degree of improvement persisted for varying 
periods. After all medication was stopped, good 
results continued for from twelve to twentj-^-one 
months in three patients. Following relief 
fourteen have not returned. One other is im- 
proved and still under treatment. Two patients 
reported return of s^^ptoms after discon- 
tinuing medication, one for six months and the 
other for four months, and the treatment was 
repeated. A fourth patient was sj^mptom-free 
for eleven months until a fistula-in-ano de- 
veloped. Treatment was repeated in this case 
also. 


American Journal of Surgery 



Rebell, Bradford — Rectal Stricture 


215 


Table ii 

THERAPY AND RESULTS IN TWENTY-FOUR PATIENTS WITH RECTAL STRICTURE DUE TO 

LYMPHOGRANULOMA VENEREUM 


Case 

Daily 

Dose 

(mg.) 

Dura- 

tion 

(wk.) 

Rest 

Period 

(wk.) 

Additional 

Therapy 

Results 

1 

1 

Comments 

I 

3 

20 

none 

sulfathiazole for 

Improved in 2 wk.; dilation 

Failed to return %vhile on treat- 


10 

22 

none 

8 wk. 

minimal 

ment 

2 

6 

4 

none 

sulfathiazole 

Improved in 2 wk.; dilation 

Failed to return after 4 wk. 






minimal 


3 

5 

3 

none 

sulfadiazine for 3 

No improvement; not dilated 

Failed to return after 5 wk. 


3 

I 

none 

wk. 




5 


none 




4 

5 

5 

none 

i 

none 

Improved in i wk.; dilation 

Failed to return after 5 wk. 






minimal 


5 

5 

4 

21 

none 

Improved in 4 wk.; stricture 

Failed to return while on treat- 


5 

8 

none 


dilated 

ment 

6 

5 

I 

none 

sulfonamides 

Dilated to 18 mm. after i wk. 

Failed to return after dilation 

7 

5 

13 

26 

none 

Symptoms recurred during 

Treatment repeated; failed to 


5 

8 

none 


rest period 

return 

8 

5 

2 

none 

none 

Improved in i wk. 

Failed to return after 2 wk. 

9 

5 

14 

none 

sulfathiazole for 

Dilated to 1 5 mm. in 3 wk. 

Failed to return after 14 wk. 





8 wk. 



10 

6 

I 

none 

sulfathiazole 

Improved in 2 wk.; not di- 

Failed to return while on treat- 


9 

5 

none 


lated; symptoms returned; 

ment 


10 

2 

17 


improved in 2 wk. 



10 

I I 

none 




1 1 

5 

5 

none 

sulfadiazine for i 

Dilated to 1 2 mm. in 5 wk. 

Observed 1 5 months with no 


10 

14 

56 

wk. 


recurrence 

12 

10 

1 

none 

sulfonamides 

Improved in i wk.; dilated 

Failed to return while on treat- 


15 

13 

none 


to 12 mm. 

ment 

13 

5 

. 

none 

none 

Relieved in i wk.; dilated to 

Failed to return for follow-up 


10 

12 

none 

none 

12 mm. 



2 


none 

none 



14 

3 

3 

none 

none 

Improved in 4 wk.; dilated 

Stricture narrowed during 29 wk. 


5 

16 

16 

none 

to 12 mm. 

rest period 


5 

2 

none 

none 




15 

2 

4 

none 




5 

16 

none 

none 




15 

5 

none 

none 

Symptoms recurred; dilated 

Still under observation after 13 


10 

24 

29 

none 

to 12 mm. again 

wk. with satisfactory result 


10 

16 

13 

none 



15 

5 

I 

none 

sulfadiazine 5 wk. 

Improved in 4 wk.; dilated 

Failed to return after observa- 


10 

3 

none 


to 18 mm. in 10 wk. 

tion for 6 wk. 


15 

12 

7 

sulladiazine 12 




15 

12 

6 

wk. 

t 



January, ig^o 



2 i 6 Rebell, Bradford — Rectal Stricture 


Table ii (Continued) 


Case 

Daily 

Dose 

(mg.) 

Dura- 

tion 

(wk.) 

Ilest 

Period 

(wk.) 

Additional 

Therapy 

Results 

Comments 

16 

5 

26 

none 

none 

No improvement noted; not 

Permanent colostomy i year 


10 

5 

6 

none 

dilated 

prior to present treatment 


>5 

13 

d.c. 

none 



17 

5 

3 

none 

sulfadiazine4\vk. 

Relieved in 2)4 wk.; dilated 

Failed to return while on treat- 


'5 

$ 

none 

! 

to 12 mm. in 8 wk. 

ment 

18 

10 

10 

none 

sulfadiazine 5 wk. 

Relieved in i wk.; dilated to 

Still under observation after 21 


15 

12 

' i 


18 mm. in 10 wk. 

months with no recurrence 


15 

5 

81 


- 


19 

3 

6 

none 

sulfathiazole for 

Improved in 1 wk.; dilated 

Failed to return after 6 wk. 





4 wk. 

to 15 mm. 


20 

3 

4 

none 

none 

Relieved in 4 wk. 

Failed to return 

21 

1 

I 

none 

none 

Improved in 2 wk. 

Observed 12 months with no 


5 

14 

13 

none 


recurrence 


5 

8 

52 

none 



22 

5 

I 

none 

sulfonamides for 

Improved in 2 wk. 

Still under treatment 


10 

4 

none 

2 wk. 



23 

5 

22 

48 

sulfadiazine for 2 

Dilated to 15 mm. in 3 wk. 

Observed 1 1 months; anal fistula 


5 

2 

none 

wk. 


developed; treatment repeated 


10 

6 

7 




24 

5 

2 

none 

sulfadiazine for 4 

Improved in 3 wk.; not 

Colostomy recommended prior 


10 

2 

none 

wk. 

dilated 

to treatment; failed to return 



I 

none 



after 5 wk. 


* Information not recorded. 


One individual was not relieved and failed 
to keep appointments. A second with a tubular 
stricture who had a permanent colostomy prior 
to diethylstilbestrol therapy obtained no relief. 

Our experience coincides with that of other 
investigators who have encountered lack of 
cooperation in patients with this disorder.- 
Several either took the medication irregularly 
or failed to return for scheduled examinations 
when symptomatic relief was achieved. Our 
analysis, therefore, is not as complete as could 
be desired. 

When discomfort had lessened and the 
stricture appeared more pliable, attempts at 
digital dilatation were made in some instances. 

In three individuals with annular strictures the 
lumen could be gradually enlarged to permit 
the passage of a sigmoidoscope i8 mm. in 
diameter. Dilatation was accomplished without 
anesthesia and with a minimum of pain. A 
lumen of this caliber or even slightly smaller 
permitted the passage of the fecal stream with 

American Journal oj Surgery 


subjective satisfaction. Dilatation to 15 mm. 
was accomplished in three individuals and it 
was found that the stricture had little tendency 
to contract again during the period of observa- 
tion. Dilatation to 12 mm. was possible in five. 
. In one negro woman, aged forty-four, relief 
of symptoms has continued and a lumen of 
18 mm. has been maintained for twenty-one 
months after discontinuing medication, the 
longest interval in the series up to the time of 
this report. The most striking benefit was noted 
in a negro man, aged thirty-nine, who had a 
partial intestinal obstruction due to an annular 
stricture at the 8 cm. level and in whom an 
emergency colostomy was contemplated. After 
he had taken 5 mg. of diethylstilbestrol daily 
for ten days, he experienced satisfactory bowel 
evacuations and relief of rectal discomfort. 
This man continued estrogenic therapy for five 
weeks with progressive improvement so that 
consideration of colostomy was abandoned. 
When first seen by us the woman with the 












































Rebell, Bradford — Rectal Stricture 


217 


permanent colostomy exhibited an extremely 
snug tubular stricture admitting not even a 
finger tip. She resisted digital dilatation after 
having taken increasing amounts of diethyl- 
stilbestrol for forty-two weeks. 

The group of patients treated with diethyl- 
stilbestrol has been observed for three years. In 
no case has colostomy been indicated nor does 
it seem likely that it will need to be recom- 
mended for any of these patients. 

SUMMARY 

Our experience and the reports of other in- 
vestigators support the conclusion of Martin 
and Bacon® that granulomatous rectal stric- 
tures cannot be cured by any treatment now 
known. However, in a small series of patients 
observed by us over a period of three years 
estrogenic therapy has proved distinctly supe- 
rior to any other remedy. Compared with other 
methods used in the larger series diethyl- 
stilbestrol given orally brought earlier and 
more conspicuous symptomatic relief, longer 
duration of benefit and more satisfactory 
dilatation of the stricture. This was true in 
t^venty-two of twenty-four persons. 

In adequate dosage diethylstilbestrol appears 
to reduce the need for colostomy drastically in 
persons with this disorder. Permanent colos- 
tomy was required in approximately one-third 
of the larger series (Group i.) It was not indi- 
cated in any of the twenty-four persons in 
Group II. 

The daily dosage of diethylstilbestrol neces- 
sary to achieve relief ranges from 3 mg. to 15 
mg. The majority of individuals responded 
favorably to a daily dose of not more than 5 mg. 
Duration of treatment varies with the indi- 
vidual but a minimum of four weeks appears 
desirable. Repeated courses of diethylstilbestrol 
may be indicated in from 10 to 15 per cent of 
patients. Relief, once obtained, tends to persist 
for at least four months. Recurrence of symp- 
toms calls for another course of diethylstil- 
bestrol in amounts previously found effective. 

CONCLUSIONS 

1 . Benign rectal stricture is a frequent com- 
plication of lymphogranuloma venereum and is 
more common in women than in men. 

2. Various methods of therapy prior to the 
use of diethylstilbestrol have been disappoint- 
ing and transient in their results. 

3. Rectal strictures of the annular type 
resulting from lymphogranuloma venereum 

January, ig^o 


respond favorably in both male and female 
to diethylstilbestrol given daily by mouth. 

4. Response to medication and dilatation in 
strictures of the tubular type is not encouraging. 

5. This treatment often appeared to obviate 
the necessity for a permanent colostomy. It 
certainly deserves a thorough trial before 
surgery is recommended. 

6. Adequate diethylstilbestrol therapy fol- 
lowed by dilatation provides a more satisfactorj'- 
form of relief for persons with granulomatous 
rectal stricture than that obtained from any 
other regimen we have used. 

REFERENCES 

1. DeWolf, H. F. and Van Cleve, J. V. Lympho- 

granuloma inguinale. J. A. M. A., gg: 1065, 1932. 

2. Lee, j. and Staley, R. W. Inflammatory strictures 

of the rectum and their relation to lymphogranu- 
loma inguinale. Ann. Surg., 100: 486-495, 1934. 

3. Martin, C. F. and Bacon, H. E. Lymphogranu- 

loma inguinale or lymphopathia venerea. Internat. 
Clin., 4: 250-293, 1935. 

4. Goldman, H. Stricture of the rectum in lympho- 

granuloma venereum, pregnancy, delivery. Tr. 
Am. Prod. Soc., 43; 264-266, 1942. 

5. Seley, a. D., Vernick, S. and Goldman, H. The 

estrogen treatment of stricture of the rectum 
due to lymphogranuloma venereum. J. Clin. 
Endocrinol., 5: 301-304, 1945. 

6 . Bacon, H. E. Anus, Rectum, Sigmoid Colon. 

Philadelphia, 1941. J. B. Lippincott Co. 

7. Greenblatt, R. B. and Wermer, P. L. Lympho- 

granuloma venereum. M. Clin. North America, 
29: 663-687, 1945. 

8. Rainey, W. and Cole, W. H. Lymphogranuloma 

inguinale. Arch. Surg., 30: 820-832, 1935. 

9. Grace, A. W. Anorectal lymphogranuloma ven- 

ereum. J. A. M. A., 122: 73-78, 1943. 

10. Bacon, H. E. Rectal Stricture. Encyclopedia of 

Medicine. Philadelphia, 1934. F. A. Davis & Co. 

1 1 . Bloom, D. Strictures of the rectum due to 

lymphogranuloma inguinale. Surg., Gynec. & 
Ohst., 58: 827-840, 1934. 

12. Durand, M., Nicolas, J. and Favre, M. Lympho- 

granulomatose inguinale subaigue. Bull, et mem. 
Soc. med. d. bop. de Paris, 35: 274, 1913. 

13. Hook, W. G. and Bacon, H. E. Lymphogranuloma 

venereum. J. Missouri M. A., 36: 324-329, 1939. 

14. Hellerstrom, S. a contribution to the knowledge 

of lymphogranuloma inguinale. Ada dermat.- 
venereoL, i; 5-224, 1929. 

15. Marino, A. W. M.: The anorectal phase of lympho- 

granuloma inguinale. Ann. Surg., 102: 1086, 1935. 

1 6. Martin, C. F. and Reuther, T. F. Rectal stricture 

of lymphogranuloma venereum, Illinois M. J. 
75 •• 337-340, 1936. 

17. Stannus, H. a Sixth Venereal Disease. Baltimore, 

1933- Wm. Wood & Co. 

18. Sulzberger, M. B. and Wise, F. Lymphopathia 

venereum. J. A. M. A., gg: 1407-1410, 1932. 

19. Wolf, J. and Sulzberger, M. B. Lymphopathia 

venereum (lymphogranulomatosis inguinalis) and 
the Frei test. Brit. J. Bermat., 44; 192—193, 1932. 



> OFFICERS AND COUNCIL OF 

THE AMERICAN PROCTOLOGIC SOCIETY 

1 949-1 950 


President: Louis E. Moon, M.D., OmaAa, Nebr. 
President-Elect: Hoyt R. Allen, M.D., Little Rock, Ark. 
Vice-President: Herbert T. Hayes, M.D., Houston, Tex. 
Secretary: W. Wendell Green, M.D., Toledo, O. 
Treasurer: Rufus C. Alley, M.D., Lexington, Ky. 


Harry E. Bacon, M.D., Council 
Philadelphia, Pa. 

A. W. Martin Marino, M.D., Council 
Brooklyn, N.V. 

Newton D. Smith, M.D., Council 
Rochester, Minn. 


American Journal oj Surger},^ 



3 


Ik Bmericaii Journal of f urgerii 

VoL. Lxxix Contents • February, 1950 Number Two 


Editorial 

Progress of the Red Cross National Blood Program . . . George W. Hervey 219 

Original Articles 

Surgical Consideration in the Management of Cancer of the 

Colon Claude J. Hunt 222 

Aureomycin in Soft Tissue Infections 

Myra A. Logan, William I. Metzger, Louis T. Wright, Aaron Prigot and 

Edwin A. Robinson 229 

Soft Tissue Cover of Defects of the Lower Extremity 

Bruce C. Martin and Raymond O. Brauer 244 

Abdominal Trauma. A Clinical Study of 200 Consecutive Cases 

from the Massachusetts General Hospital 

Claude E. Welch and W. Philip Giddings 252 

An Erect Method of Myelography 

A. L. Loomis Bell, Howard O. Wunderlich, Herbert C. Fett and Champe C. Pool 259 

Threaded Wires and Pins for Longitudinal Medullary Fixation 

of Fractures of the Humerus, Radius, Ulna and Tibia 

Albert A. Schwartz and Paul H. Harmon 264 

Intraspinal Segmental Alcohol Block for Relief of Intractable 

Pain. A Preliminary Report F. Paul Ansbro 2% 

Postoperative Abdominal Wound Separation and Evisceration 

E. ]. Joergenson and Ernest T. Smith 282 

Primary Treatment of Extensive Burns Roswell K. Brown and Joseph M. Dziob 288 

Special Problems in Reconstructive Surgery in the Amputee. 

Lower Extremities Frederick J. McCoy 295 

Unusual Anal, Rectal and Perirectal Tumors Palpable by Rectal 

Examination A. Oppenheim and J. P. O'Brien 302 

Conrentj Continued on Page 5 



• PROLONGED 

IH to 2 hours or more. 

• MARKED MUSCULAR RELAXATION 


spinal 

anesthesia 

mth 

PONTOCAINE® 


• WELL TOLERATED 

Little or no fall in blood pressure, low 
incidence of nausea or post-spinal headache. 


HYDROCHLORIDE 

BRAND OF 

TETRACAINE HYDROCHLORIDE 


Supplied as 1% solution (10 mg. per cc.) in 
ampuls of 2 cc., boxes of 10 and 50; and 
as “Niphanoid” powder, ampuls of 10 mg., 
15 mg., and 20 mg., boxes of 10 and 100. 




5 


Ik Rmerlcan Journal of Surgery 

Reg. U. S. Pat. Off., Nov. 3. 1936 

VoL. Lxxix Contents • February, 1950 Number Two 


Unilateral Spinal Anesthesia for Surgical Reduction of Hip 

Fractures J. Eugene Ruben and Patricid'Mary Kamsler 312 


Streamlined Articles 

Surgical Treatment of Cancer of the Esophagus 

Earl J. Halligan, Louis L. Per\el and J. Kenneth Catlaw 318 

Carotid-jugular Arteriovenous Fistula .Joseph I. Anton and H. Harvey Cooperman 324 

Elephantiasis and the Kondoleon Operation. A Twenty-year 

Postoperative Follow-up . . Mandel Weinstein and Morton Roberts 327 

Extraperitoneal Perforation of the Rectum LeonJ.Taubenhaus 332 


Case Reports 

Resectable Carcinoma of the Cardia of the Stomach with Symp- 
toms of Three Years’ Duration 

Joseph E. MacManus, Lawrence S. Mann and Ben L. Leming 335 

Evagination of Ileum through Patent Omphalomesenteric Duct 

Alton G. Brown and F. G. Cain 339 

Primary Ovarian Pregnancy .... Aaron Hirsch and Richard Waltman 341 

Successful Anastomosis of Severed Brachial Artery 

L. Kraeer Ferguson and James H. Holt 344 

Repair and Stabiliz,ation of the First Carpometacarpal Joint 

A. A. Michele, H. L. SJpnner and F. J. Krueger 348 


J^ew Instrument 

New Prosthesis for Prolapse of the Rectum Edward E. Jemerin 350 

General Information on Page 6 Advertising Index on 3rd Cover 



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of article; name of periodical; volume, page 
and year. The following may be used as 
a model: 

Phaneuf, Louis E. Indications and technique. 

Am. J. Surg., 25: 446, 193?. 

The author should always place his full address on 
his manuscript. 

The subscription price of The Americak Journal of Sur- 
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Address all correspondence to 

Ihe Bmcficaft Journal of ^urgorg 

49 WEST 45TH STREET • NEW YORK 19 





fhe Bmedcati Journal of Surgery 

Copyright, 1950 by The American Journal of Surgery, Inc. 

A PRACTICAL JOURNAL BUILT ON MERIT 

Fifty'Yiinth Year of Publication 

VOL. Lxxix FEBRUARY, 1950 number two 


MiioM 

PROGRESS OF THE RED CROSS 
NATIONAL BLOOD PROGRAM 


O N the occasion of accepting the 
resignation of Basil O’Connor as 
President of the American National 
Red Cross President Truman in a compli- 
mentary vein observed that the National 
Blood Program, inaugurated during the 
O’Connor regime, may well become the 
greatest single health activity in history. 
That statement can be interpreted to mean 
that this newest humanitarian enterprise 
of the Red Cross is on the road to becoming 
an effective adjunct to the medical and 
surgical profession of the nation on a scale 
unenvisioned as yet by the populace at 
large. No other conclusion can be drawn 
from the record of accomplishment during 
the comparatively short period the pro- 
gram has been in operation. 

In embarking on this far reaching project 
the Red Cross was able to utilize knowledge 
gained during the war period when the 
organization collected more than 13,000,000 
pints of blood for distribution to the armed 
services. However, numerous operational 
problems not previously encountered had 
to be resolved during the planning stage of 
the peacetime undertaking. Obviously, 
under changed postwar conditions a series 
of loosely federated, local programs would 


be ill adapted to function as an efficient 
entity in time of serious disaster. The 
project was founded on a philosophy of 
cohesiveness and high standards, thus 
attracting the support of leading scientific 
groups and individuals. 

With the endorsement of interested gov- 
ernmental agencies, the Division of Medical 
Sciences of the National Research Council, 
and a number of non-governmental agencies 
concerned with health, the first unit of the 
National Blood Program was instituted on 
January 12, 1948, by the activation of a 
blood-collecting and processing center at 
Rochester, New York, as the focal point 
for a regional program in eleven counties. 
Under the leadership of Dr. Ross T. 
Mclntire, former Surgeon General of the 
Navy, expansion has been rapid. Including 
an all-mobile unit service in the State of 
Massachusetts there are now thirty re- 
gional programs in operation extending 
from coast to coast. These include two 
which were activated in September, 1949, 
with centers located at Savannah, Georgia, 
and Norfolk, Virginia, respectively. 

In addition there are many local Red 
Cross blood donor programs such as the 
one in Greater New York. These local pro- 
219 




220 


Editorial 


grams which exist in scores of cities are 
not at this time a part of the national Red 
Cross program but are helping to supply 
blood for local needs. 

From January, 1948, through August, 
1949, the total blood collections through 
the National Blood Program amounted to 
344,213 pints. That large quantity was 
voluntarily donated by 288,883 separate 
persons. The blood was made available 
without charge to physicians and surgeons 
principally for use at 1,268 hospitals and 
some was distributed to seventy clinics. 
Mobile unit operations were carried on in 
1,034 communities. Considering that one- 
half of the regional programs in existence 
at the end of August, 1949, had been in 
operation less than a year, a vigorous, 
accelerated growth is certainly in prospect. 

The maintenance of complete records 
at the regional centers assures that the 
program, besides supplying the usual 
peacetime demand for blood in the com- 
munities served, can move quickly to meet 
the blood needs of a major emergency or 
national defense. The information regard- 
ing the blood group of each donor, his Rh 
factor, address and the answers to perti- 
nent medical history questions are entered 
on a registration card. Moreover, several 
hundred chapters which have sponsored 
mobile unit visits possess blood group 
registers pertaining to the donors in the 
smaller communities. Whenever the call 
may come, the Red Cross will be in posi- 
tion to refer to the data on file and to know 
the total supply and location of the blood 
forthcoming. 

Much of the success of the program to 
date can be attributed to its predominantly 
medical character. Guidance is furnished 
nationally by an advisory committee which 
is identical with the Committee on Blood 
and Blood Derivatives of the National 
Research Council of which Dr. Charles A. 
Janeway of the Harvard Medical School 
is chairman. The membership includes two 
distinguished surgeons. Dr. Isidor S. Rav- 
din of the University of -Pennsylvania 
Medical School and Dr. Everett I. Evans, 


of the Medical College of Virginia. On the 
national headquarters staff in Washington, 
D.C. is Dr. Louis K. Diamond, Medical 
Director of the entire program. A.t each 
regional center the professional and tech- 
nical responsibilities are similarly vested in 
a medical director. The chapter engages 
the services of a lay administrator who is in 
charge of the purely non-medical activities. 
Locally a medical advisory committee is 
responsible for professional guidance. 

A further guarantee of sound operations 
is the official policy governing expansion of 
the national program. The Red Cross 
refrains from instituting a regional center 
or program unless requested to do so by the 
chapters concerned. The application from 
the chapters must be approved by the 
county medical society, local health depart- 
ment and local hospital association in each 
community under its jurisdiction. 

Until now the major activity of the 
program has been to supply needed whole 
blood but in the future this will be only 
part of a broader program. During the 
fiscal year 1948 to 1949 the Red Cross 
issued for medical use considerable quan- 
tities of immune serum globulin, serum 
albumin, dried plasma and antihemophilic 
globulin. These products had been ob- 
tained mainly from stocks of surplus war- 
time plasma that were turned back to the 
Red Cross by the armed forces. The dried 
plasma and immune serum globulin were 
made available generally to the medical 
profession through state health depart- 
ments and serum albumin and antihemo- 
philic globulin to certain specialists engaged 
in clinical studies of these products. How- 
ever, the supplies are now greatly reduced. 
Consequently, the resources of the national 
program will be directed toward their 
replenishment. 

Plans have been formulated whereby 
plasma will be extracted from a certain 
proportion of the whole blood and sent to 
fractionation laboratories. Dried blood 
derivatives then will be sent in packaged 
form to the particular regional centers from 
which the plasma was received and will be 

American Journal of Surgery 



Editorial 


221 


distributed to hospitals for specific thera- of the chapters to recruit larger numbers of 
peutic and surgical purposes. To date the blood donors. 

demand for whole blood has been so heavy When large quantities of packaged blood 
that fractionation has been possible only derivatives can be distributed generally, a 
from small quantities of plasma. Material- new epoch in scientific achievement will 
ization of this latest phase of the project, have been reached, 
therefore, will be contingent on the ability George W. Hervey, Sc.d. 


February, ig^o 



irigiital Wicks 


SURGICAL CONSIDERATION IN THE MANAGEMENT OF 

GANGER OF THE COLON* 


Claude J. Hunt, m.d. 

Kansas City, Missouri 

O NE’S comment upon the surgical bladder, prostate or posterior vaginal wall 
treatment of cancer of the colon have too frequently been declared inoper- 
must be related to his personal ex- able and a premature palliative colostomy 
perience. With an adequate contact with has been done. We have in former years, 
this major problem all the complications because of inexperience and lack of courage, 
and complex situations must have pre- performed such an ill advised procedure 
sented themselves several times. An analy- and have subsequently learned that some 
sis or review of each of these complications more venturesome surgeon has successfully 
will materially formulate some positive removed some of these lesions. Likewise, in 
conceptions relative to future management recent years we have removed lesions on 
of similar situations. patients previously pronounced inoperable 

Palliative colostomy, for example, is elsewhere upon whom a colostomy had 
usually a procedure to be condemned. It been done. We now demand unmistakable 
gives no palliation and adds little to the evidence of inoperability before we resign 
patient’s life but contributes much to his ourselves to inaction. Ability, experience, 
discomfort. It is uncontrollable and has courage and a willingness to accept defeat 
contributed much to discredit colostomy and an increased mortality rate are essen- 
performed in association with removable tial requirements for the adequate and 
lesions. The pain and discomfort accom- proper management of these major prob- 
panying an unremoved, malignant lesion lems. The successful removal of a seemingly 
are attributed to the colostomy rather than inoperable lesion gives the surgeon a great 
to the progress of the disease. feeling of satisfaction but the performance 

A palliative colostomy is indicated only of a colostomy in a lesion of questionable 
in advanced malignancy associated with operability is not consoling, 
impending obstruction. In many instances Palliative resection may add much to the 
of such advanced states colostomy can be patient’s comfort and length of life and 
avoided by anastomosing around the lesion far exceeds in benefit a short circuit opera- 
and preserving the fecal current; or, for tion around the lesion or a colostomy. Pain 
the brief period of life remaining a diet and pressure from the gro-wth of the lesion 
without residue or liquid in character will is lessened by palliative removal. Moderate 
obviate the annoying effects of a terminal metastases is no contraindication to resec- 
colostomy. tion and the removal of adjacent involved 

Many patients who have large, fixed structures along with the lesion, when 
lesions or lesions involving adjacent intes- possible, is to be encouraged. Resection 
tines, abdominal wall, pelvic structures, even in the presence of incurability is, 

* From the Surgical Service at the Research Hospital, The Research Clinic and the Kansas City General Hospital, 

Kansas City, Mo. 


222 


American Journal oj Surgery 


Hunt — Cancer of Colon 


223 


therefore, strongly urged. The patients live 
longer and are more comfortable when the 
lesion is removed. 

DIAGNOSIS 

Any increase in resectability and five- 
year cure percentage can only be attained 
by early diagnosis and operation. A more 
general recognition of the fact that cancer 
of the colon and rectum are related to dis- 
orders of bowel function will lead to earlier 
diagnosis and earlier surgery. These are 
related to the passage of bright red blood, 
to signs of progressive obstruction or to 
soft, dark, frequent stools associated with an 
unexplained advancing secondary anemia. 

Seventy-five per cent of the lesions are 
in the left colon or rectum and, therefore, 
are accessible to digital or instrumental 
Investigation or may be studied by x-ray 
procedures. Right colon lesions may some- 
times be obscured by the opaque media, 
especially if the mesocolon is long and 
pendulous; the lesion is behind the opaque 
media and hidden from view. All unex- 
plained secondary anemias should suggest 
right colon malignancy and receive careful 
and often repeated radiographic study. 
Likewise, lesions of the splenic flexure may 
be obscured by the overlapping of the 
proximal limb over the distal when seen in 
the anteroposterior view. A lateral or 
oblique radiographic view will separate 
these structures and expose any bowel 
defect to inspection. Lesions may be missed 
by barium enema study unless these ana- 
tomic relationships are kept in mind. 

Associated Lesions. A diagnosis of can- 
cer of the colon does not mean that second- 
ary cancer or polyps may not be present 
elsewhere in the colonic tract. Careful 
investigation by x-ray study should be 
made of the entire colon. If other lesions 
are found associated with the known can- 
cer, operation may be extended to include 
a ^yide area of involved malignant or poly- 
poid bowel. The mucosal pattern of the 
colon is not shown by a plain barium enema. 
Such a procedure simply shows caliber 
narrowing, irregularity of contour or ob- 

February, ig^o 


struction. The opaque media must be 
partially expelled and air injected to con- 
trast the protruding polyps and the sur- 
rounding mucosa. The polyps are seen as 
areas of different density surrounded by a 
thin layer of barium. On many occasions 
we have observed associated polyps by this 
procedure and have been able to extend the 
scope of resection and remove the polyps 
along with the cancer. We have observed 
lesions distal from the one under primary 
consideration and have subsequently re- 
moved them by secondary surgery. 

Recently we operated upon two patients, 
both of whom within the year had a malig- 
nant lesion removed from the sigmoid. In 
one we removed a segment of involved 
abdominal wall, a secondary colonic cancer 
and some associated polyps adjacent to 
the primary operation. In the other, be- 
cause of a slow, progressing obstruction and 
pain, we did a radical, excision of the left 
colon, ovary and tube and many metastatic 
glands adherent to the iliac vessels. Both 
bowels showed polyps which we believe 
should have been found before primary 
surgery and removed along with the can- 
cer. Both had been operated upon elsewhere 
by the obstructive resection type of pro- 
cedure with inadequate bowel and mesen- 
tery removal. By this procedure of pre- 
operative investigation and wide removal 
of the bowel and all mesentery drained by 
the segment recurrences will be diminished 
and secondary surgery will be minimal. 

Cancer Potentialities. The progress of 
cancer of the colon and the complications 
which develop from it are directly related 
to the segment of the bowel in which it is 
located. Lesions on the right side produce 
ulceration, infection and a pronounced 
anemia and on the left side bleeding or 
progressive obstruction. Right colon lesions 
rarely obstruct or require stage operations. 
Fever, increased leukocyte count and local 
evidence of a pericolic inflammation will 
usually subside with sulfonamides, bowel 
evacuation and putting the bowel at rest 
by the Miller- Abbott tube. Lesions on the 
left side grow out into the bowel as an 



224 


Hunt — Cancer of Colon 


adenoma or polyp and bleed and obstruct 
as they increase in size; or they infiltrate 
the intermuscular lymphatics and produce 
an annular or canalizing obstructing lesion. 
Lahejr has emphasized the fact that these 
lesions do not produce the profound anemia 
often associated with cachexia so charac- 
teristic of right colon lesions. Were this so 
it could be said that they would be inoper- 
able because of metastasis. Canalization 
represents an advanced infiltration of the 
lymphatics along the intermuscular spaces 
of the bowel. 

OPERATION 

Preparation. The essentials of blood, 
fluid, protein and vitamin restoration are 
recognized. Surgical approach is facilitated 
by a clean, unobstructed bowel and danger 
of peritonitis is enormously reduced by a 
week of administration of sulfasuxidine or 
sulfathaladine. Poth has demonstrated ex- 
perimentally the value of these two inhibit- 
ing bactericidal drugs and he has found 
that healing of the anastomosis was by 
early formation of fibroblasts when sulfa- 
suxidine had been given for a week preced- 
ing operation ; whereas, without these drugs 
healing was by secondary intention with a 
noticeable absence of fibroblasts. 

Streptomycin in my opinion is short 
lived, four to five days. It does for a time 
reduce colon bacteria but it is not sus- 
tained. It is most valuable when sulfonam- 
ides are precluded because of obstruction. 

Surgical Approach. The problem of sur- 
gical approach is controversial. A friendly 
rivalry exists between those who advocate 
a stage obstructive type of resection and 
those who insist upon resection and primary 
anastomosis, a one-stage procedure. There 
must of necessity be a middle-of-the-road 
approach to the problem. Many patients 
thought to be suitable for a one-stage pro- 
cedure are found at operation to be unsuit- 
able for such an approach because of a 
variable degree of chronic obstruction, 
fixation, penetration or surrounding inflam- 
mation. A stage approach to the problem 
becomes obvious. Proximal decompression 


or a first stage anastomosis around the 
lesion to divert the fecal current as an ileo- 
colostomy for a right colon lesion or a 
transverse colosigmoldostomy for a splenic 
lesion may be done. 

One-stage Operations. Conditions for 
resection and primary anastomosis are 
very exacting and the procedure me- 
ticulous. There must be no obstruction, 
the bowel must be thoroughly clean, there 
must be no tension of approximated seg- 
ments of bowel and the blood supply must 
not be compromised. 

In the absence of obstruction, inflamma- 
tion or fixation, primary resection and 
anastomosis can be done in any segment of 
the colon with a ver}' low mortality. 

We are not interested in the closed 
method of anastomosis. We are sure under 
ideal conditions, which can be obtained in 
unobstructed colon lesions, open operation 
adds little risk of peritonitis but affords 
accuracy of suture, minimum inversion of 
the bowel, controls hemostasis and affords 
inspection for adjacent polyps which in our 
experience are frequently observed. We 
have removed many which would have 
been missed by the closed method of 
anastomosis. 

We believe peritonitis rarel}' results from 
an open anastomosis under appropriate 
conditions but is the result of continued 
contamination by leakage or tissue necrosis. 

Obstructive Resection (Stage Procedure). 
Mikulicz in 1903 gave the first report of a 
series of patients managed by exterioriza- 
tion. This contributed a great deal to the 
surgical approach to cancer of the colon. It 
became very widely emploj'^ed and still is 
an approach preferable for the occasional 
operator. Many objections soon became 
apparent, objections relating to implants 
in the abdominal wall and inadequate 
removal of the gland-bearing mesentery. 
This was largely overcome by the standard- 
ized procedure of wide obstructive resec- 
tion advocated by Rankin and Lahey. We 
are certain that in limited regions of the 
left colon as wide an area of mesentery and 
as extensive a segment of bowel can be 

American Journal oj Surgery 



Hunt — Cancer of Colon 


225 


removed by this method as by primary re- 
section and anastomosis. Occasionally, due 
to some degree of proximal edema or an 
inadequately clean proximal bowel primary 
anastomosis must be abandoned and the 
obstructive type of resection substituted. 
A direct answer to the merits of primary 
anastomosis versus obstructive resection 
from the point of view of operative mor- 
tality in large groups of cases is unques- 
tionably in favor of the latter. We have 
seen no report whose results by the one- 
stage operation excels those obtained by 
Lahey, Jones, Rankin and Dixon with 
obstructive resection. 

Obstruction. Obstruction must be abol- 
ished before resection of the lesion is at- 
tempted. This is best done by cecostomy 
or right transverse colon colostomy. We 
prefer cecostomy for all obstructions proxi- 
mal to the sigmoid and transverse colon 
colostomy for those of the sigmoid and 
rectosigmoid. In the former we want free 
mobility of the transverse colon; in the 
latter the bowel can be better irrigated and 
cleaned through a right colostomy and its 
location in the right transverse colon will 
not restrict sigmoid or rectosigmoid resec- 
tion and anastomosis. 

Obstructive colon lesions form a closed 
loop type of obstruction and are compar- 
able to strangulated small bowel obstruc- 
tion. The blood supply to the bowel becomes 
impaired as distention progresses and gan- 
grene and perforation may occur. The 
bowel distends to an enormous size. In a 
thin individual the contour can be seen 
outlining the course of the colon. The wall 
is paper thin and difficult to manipulate 
surgically. The most accessible site for 
decompression is usually the cecum as the 
transverse colon is pushed up under the 
liver by the’ enormously distended cecum. 
This we deflate by needle puncture and 
obstructively exteriorize a small segment 
. of the cecum, close the abdomen around it 
and then insert through our cecostomy 
clamp a catheter into the bowel which 
serves as a vent for the escape of gas until 
the bowel adheres to the abdominal wall 

February, 1950 


when the clamp can be removed and the 
bowel irrigated. 

SEGMENTAL CONSIDERATION OF COLON 
MALIGNANCY 

Right Colon. Right colon lesions de- 
serve detailed consideration from the point 
of view of surgical removal. Segmental or 
partial removal has no part in surgery of 
the right colon. It is entirely inadequate 
and falls far short of removing all the 
gland-bearing tissue. The fan-like distribu- 
tion of the mesentery of the right colon 
extends from the terminal ileum to beyond 
the hepatic flexure and spreads out across 
a portion of the duodenum and the inferior 
border of the pancreas to focus at the root 
of the superior mesentery vessels where the 
sentinel glands of this large, gland-bearing 
area drain into the portal and aortic sys- 
tem. Any resection short of removal of the 
entire gland-bearing structure is inade- 
quate. Vascularity of the right colon is 
variable and viability of the transverse 
colon may be inadequate for a distance 
after ligation of the mid-colic artery. We 
lost one patient by necrosis of the closed 
stump of the transverse colon after right 
colectomy. Technical procedures are de- 
pendent upon the local condition of the 
lesion. Usually, primary resection can be 
performed. We prefer union of ileum to 
colon by an end-to-side anastomosis; it 
more nearly approaches the normal re- 
lationship of ileum to cecum. The side-to- 
side method is excellent; a wide opening 
can be made. No long, blind end of bowel 
should be left. We operated upon one 
enterocele of the ileum in the blind end of 
a side-to-side ileocolostomy. An end-to-end 
anastomosis is excellent but is difficult 
sometimes because of caliber differences. 
In either instance proximal enterostomy 
is no longer indicated. A Miller-Abbott 
tube is useful but with a good stoma ob- 
struction from edema will not develop. 
Negative gastric suction is always used for 
a few days. 

Hepatic obstructive lesions require pre- 
liminary ileocolostomy prior to resection 



226 


Hunt — Cancer of Colon 


and fixed inflammatory lesions without 
obstruction may have complete diversion 
of the intestinal stream by transaction of 
the terminal ileum, closure of the distal end 
and an ileocolostomy. 

Transverse Colon. Transverse colon le- 
sions should be diagnosed early. Like the 
cecal and sigmoid lesions they are more 
accessible to palpation. Often they are non- 
obstructive and primary resection with 
anastomosis is feasible. We have always 
found it advisable to mobilize both the 
hepatic and splenic flexure to afford wide 
resection and approximation without ten- 
sion. Cecostomy effectively relieves ob- 
struction and in no way limits mobilization 
and resection. 

We have used resection in several cases 
in which a segment of small bowel was 
involved by continuity with the neoplasm. 
Recently a large lesion had several fistulous 
tracts into a segment of jejunum. This 
mass of colon and small bowel was excised 
and appropriate anastomoses were made; 
recovery was uneventful. Two cases of can- 
cer of the transverse colon so involved the 
stomach that partial resection of the stom- 
ach was necessary. Both patients survived 
and have lived more than three years. 

Splenic Flexure. The symptoms of 
splenic flexure lesions are remote and are 
referred largely to the right side of the 
abdomen. The lesion is high, inaccessible 
and a variable degree of chronic obstruc- 
tion or actual obstruction is present before 
the diagnosis is made. Delay has often 
resulted in fixation, penetration and abscess 
formation. In our experience it has been 
wise, usually, to do proximal surgical de- 
compression by cecostomy prior to at- 
tempted resection. This we consider an 
excellent routine procedure as it affords a 
much needed vent for escape of gas follow- 
ing resection and anastomosis. It acts as 
a complementary decompression. We be- 
lieve that with splenic flexure lesions the 
entire descending colon should be removed 
and the anastomosis made between the 
transverse colon and sigmoid. This affords 
a wide removal of gland-bearing tissue and 


affords anastomosis of segments that are 
freely movable and are largely covered by 
serosa. The descending colon is only par- 
tially peritonealized and is a poor structure 
for anastomosis. Many unknown, small 
polyps are frequently seen in a resected 
specimen of this extent. 

Descending Colon and Sigmoid. The de- 
scending colon has an inadequate peri- 
toneal covering, little or no mesentery and 
poor mobility. A wide removal of the entire 
descending colon, the splenic flexure and a 
segment of the upper sigmoid with anasto- 
mosis of the transverse colon to the sigmoid 
adequately removes a wide area of gland- 
bearing tissue and any associated polyps 
and approximates without tension seg- 
ments of bowel more suitable for end-to-end 
anastomosis. 

Sigmoidal lesions often present local 
conditions suggesting inoperability. Fixa- 
tion to the ureter and iliac vessels may be 
extensive but protracted investigation often 
discovers a line of cleavage and makes 
extirpation possible. By exposing the ureter 
above the lesion and following downward 
it can be isolated and a plane entered which 
assists in freeing the lesion from important 
vascular structures. 

Complications of fixation, metastases 
and extension require expanding the scope 
of surgery if resection is feasible. Three 
times a ureter has been excised along with 
the lesion without subsequent removal of 
the associated kidney. The entire left lobe 
of the liver was removed because of a pro- 
truding, pedunculated, metastatic mass in 
two Instances during the abdominal phase 
of a Miles’ resection. Small bowels were 
involved by continuity in several instances, 
both in sigmoid and transverse colon le- 
sions, and mass resection with appropriate 
end-to-end anastomosis was done without 
incident. The transverse colon was involved 
by continuity from a sigmoid lesion and 
the entire segment of bowel was removed . 
without technical difficulty or delayed re- 
covery. We approach all malignant lesions 
of the colon and of the rectum with only 
one thought in mind, that of removal. If 

American Journal of Surgery 



Hunt — Cancer of Colon 


227 


this cannot be accomplished, the primary 
lesion is excised if anatomically possible 
and expedient. 

Low Sigmoid. For lesions of the low 
sigmoid in which we were unable to do an 
obstructive type of resection and in which 
we at that time did not do a primary anas- 
tomosis for left colon lesions, we would 
often do a Hartmann type of operation 
rather than an abdominoperineal resection. 

I well recall how favorably these patients 
recovered and how many of them subse- 
quently remained well for a long period of 
time. One patient in her fifteenth year fol- 
lowing such an operation had no evidence 
of recurrence. Another, eight years after 
this procedure, remained well. 

Dixon added much to the comfort of 
these patients through preservation of 
bowel continuity by his anterior type of 
anastomosis. We have had excellent -suc- 
cess with this procedure and we believe 
that it is a splendid one in elderly individ- 
uals with short life expectancy and a mov- 
able lesion without apparent metastasis. 

Rectosigmoid. Below the pelvic peri- 
toneum difficulties are encountered in the 
procedure. The lower segment has no peri- 
toneal investment. The tissues below the 
pelvic peritoneum are susceptible to infec- 
tion and accuracy of suture due to inacces- 
sibility is apparent. We believe this, 
however, to be a practical operation and 
one with a low mortality rate if performed 
under proper conditions and with meticu- 
lous technic. A wide resection can be done, 
the mesentery above can be removed and 
the bowel excised sufficiently far below 
the lesion to include retrograde extension, 
which is rare and usually not beyond 2 
to 3 cm. 

Too many lesions because of fixation or 
extension to bladder or female pelvic struc- 
ture are thought to be inoperable and a 
colostomy is performed. We believe resec- 
tion should be extended to the point of 
removal of a bladder segment, pelvic ad- 
nexa or hysterectomy. This we have done. 
In one instance a segment of the bladder 
was removed along with the lesion and 

February, 1950 


several times adnexal tissue or uterus 
comprised part of the removed specimen. 

Babcock, Bacon, Best, Waugh, Wan- 
gensteen and others are enthusiastically 
supporting the sphincter preservation^op- 
eration for many lesions well below the 
pelvic peritoneum. Their reported results 
well support their contention of the desir- 
ability of maintaining bowel continuity 
and sphincter preservation. The procedure 
at present is controversial. 

SUMMARY 

1. Palliative colostomy is mentioned 
only to be condemned as a procedure add- 
ing little to life expectancy and much to 
discomfort. Many lesions that appear in- 
operable can, by more careful investigation, 
be removed or circumvented by iliocolos- 
tomy or coloslgmoidosto'my, thus prevent- 
ing colostomy. 

2. Mortality studies aid in future man- 
agement as many errors can be prevented by 
a careful evaluation of previous experience. 

3. Age is no barrier to the development 
of cancer and advanced age is no contra- 
indication to surgery. Cases are cited. 

4. Emphasis is placed on the early mani- 
festations of cancer of the colon and meth- 
ods of investigation are discussed. 

5. The importance of detecting multiple 
or associated benign and malignant lesions 
is stressed and cases of such associated 
lesions are reviewed. 

6. Preparation and surgical approach to 
the problems are discussed and the indica- 
tions and merits of both primary and ob- 
structive resections are presented. 

7. The importance of proximal surgical 
decompression prior to resection of obstruc- 
ing neoplasms of the colon is stressed. 

8. The management and indications for 
certain procedures related to the various 
segments of the colon are specifically men- 
tioned, and the clinical manifestations, 
potentialities for complications and manner 
of approach are presented. 

9. Advancement in the surgical approach 
of lesions of the low sigmoid and rectosig- 
moid are described and the anterior type 



228 


Hunt — Cancer of Colon 


of resection urged. Complementary colos- 
tomy is not to be condemned but rather 
advised as a safety measure. 

REFERENCES 

1. Dixon, Claude F. Safety factors in surgery of the 

colon. Chicago M. Soc. Bull., August, 1948. 

2. Dixon, Claude F. Treatment phlebitis by leg 

bandage. Personal communications. 


3. Rankin, F. W. The principles of surgery of the eolon. 

Surg., Gyncc. & Obst., 72: 332-340, 1941. 

4. Lahex, F. H. Discussion of the modified Mikuliez 

operation for carcinoma of the colon and its tech- 
nique. 5 . Clin. North America, 26: 610-622, 1946. 

5. Bahcock, W. W. and Bacon, H. E. One-stage 

Abdominoperineal proctosigmoidectomy. S. Clin, 
North America, 22: 1631-1662, 1942. 

6. Best, Russell. Proctosigmoidostomy. Western 

Surgical Association Meeting, St. Louis, Mo., 
December, 1948. (To be published.) 


Pulsating exophthalmos occasionally occurs in patients with recent 
fractures involving the base of the skull. An aneurysm of the carotid sinus 
has resulted and produced the aforementioned clinical syndrome. If con- 
servative measures are of no avail, one must resort to radical surgery. Usu- 
ally ligation of the internal carotid artery in two stages is sufficient to pro- 
duce a cure. At the first stage only a partial occlusion is effected by the 
heavy silk ligature; later the artery is completely closed and at this same 
sitting the internal jugular vein is also ligated. Should further surgery 
eventually prove necessary, one w'ould have to resort to intracranial liga- 
tion of the internal carotid artery supplement by electrocoagulation of the 
ophthalmic arteries. (Richard A. Leonardo, M.D.) 


American Journal of Surgery 



AUREOMYCIN IN SOFT TISSUE INFECTIONS* 


Myra A. Logan, m.d., William I. Metzger, pH.d., Louis T. Wright, m.d., 
Aaron Prigot, m.d. and Edwin A. Robinson, m.d. 

New York, New York 


A UREOMYCIN, an antibiotic sub- 
yA stance introduced by Duggar and 
associates,^ has an unusually wide 
range of antimicrobial activity. This has 
been proven by many laboratory^”®^ and 
clinical studies.‘^~^^ 

The use of other antibiotics in surgical 
infections has been attended with certain 
difficulties. Meleney and his associates,^® 
using bacitracin systemically, showed that 
it had a nephrotoxic factor. The studies of 
Pulaski and co-workers^® with strepto- 
mycin proved that it was sometimes toxic 
in therapeutic doses. In view of these facts 
the relative lack of toxicity of aureomycin 
in therapeutic dosage was of especial inter- 
est. Its value seemed enhanced by the fact 
that it could be administered orally, intra- 
venously or intramuscularly with effective 
results. Aureomycin was used in conjunc- 
tion with surgery at Harlem Hospital in a 
series of cases of established peritonitis,^® 
with excellent results. For these reasons it 
was decided to undertake a study of its 
value in surgical infections of the soft 
tissues. 

The following is a report of our results 
obtained in eighty-two cases of such infec- 
tions (Table i): Surgery was employed 
when indicated but aureomycin decreased 
the necessity for operative intervention. 

CELLULITIS 

Forty-two patients with cellulitis were 
treated with aureomycin. (Table ii.) In 
approximately 50 per cent of these pa- 
tients the infection resulted from puncture 
wounds or small lacerations. All patients 
were acutely ill, showed high temperatures, 
leukocytosis and signs of inflammation of 
the body area involved. Cultures of closed 


infections were attempted by aspiration 
but this technic did not prove useful. 

In the twenty-one most serious cases an 
initial intravenous injection of 300 mg. of 
aureomycin dissolved in 500 cc. of a 5 per 
cent glucose in distilled water was given, t 


Table i 

No. 

of 

Diagnosis Cases 

Cellulitis with and without lymphangitis 42 

Ischiorectal abscesses 9 

Infected ulcers of the leg 5 

Lymphadenitis 5 

Traumatic cases: 

Human bite of hand 2 

Traumatic amputation 2 

Deep stab wound of thigh and buttock i 

Lacerated wound of neck and trachea i 

Thrombophlebitis of axillary vein and sub- 
clavian vein following laceration of finger . . . i 7 

Gas gangrene infections 4 

Carbuncles 2 

Septicemia: 

Paracolon bacillus bacteremia i 

Aerobacter aerogenes bacteremia with menin- 
gitis I 2 

Rat bite fever l 

Urinary extravasation i 

Furunculosis, generalized, severe i 

Pyoderma of scalp i 

Erysipelas of face i 

Postpartum mastitis l 

Total 82 


This was repeated twelve hours later. Be- 
ginning the second day 250 mg. of oral 
aureomycin was administered three times 
a day until the infection was controlled. 
In the remaining twenty-one cases the 
oral administration of the drug sufficed. 
In all instances there was marked clinical 
improvement as evidenced by reduction of 
temperature and decreased pain and swell- 

t The aureomycin used was furnished through the 
courtly of the Lederle Laboratories Division of the 
American Cyanamid Co., Pearl River, N. Y. 


* From the Surgical S^ice and Department of Pathology of Harlem Hospital, Department of Hospitals, Nev 
1 ork, N.Y. Aided by a grant from the Harlem Hospital Surgical Research Fund, Inc. 


February^, ig^o 


229 



230 


Logan et al. — ^Aureomycin in Tissue Infections 


Table ii 

CELLULITIS 


Series 

No. 

Case 

No. 

Age 

and 

Se.\' 

Site 

Organism Isolated 

Total 

Dose 

in 

Gm. 

Days 

under 

Treat- 

ment 

Surgery 

I 

48-25609 

42-F 

Forehead 

Beta hemolytic streptococcus; 
non-liemolytic staphylococ- 
cus albus 

4.2 

6 

None 

2 

49-244 

87-F 

Cliest wall 

Beta hcmolj'tic streptococcus 

2.0 

10 

None 

3 

49-854 

42-F 

Leg 

No culture obtainable 

7.2 

10 

None 

4 

48-23699 

48-iM 

Chest wall 

Beta hemolytic streptococcus 

5- > 

7 

None 

5 

49-330 

29-F 

Leg 

Beta hemolytic streptococcus 

3-7 

6 

None 

6 

49-1985 

3 -M 

forehead 

Beta hcmoli'tic streptococcus 

5-2 

7 

None 

7 

49-1918 

26-M 

Forearm 

Coagulase positive hemolytic; 
.staphylococcus albus 

5-2 

7 

None 

8 

49*100 

38-F 

Neck 

No culture obtainable 

10.8 

■ 5 

None 

9 

* 

46-M 

Nose 

Staphj'lococcus albus 

4.0 

3 

Incision and drainage 
before therapj' 

10 

49-2306 

22-F 

Buttock 

Gamma streptococcus; cs- 
chcrichia coli 

6.4 

6 

None 

I I 

49-3988 

22-F 

Buttock 

Anaerobic streptococcus; pro- 
teus vulgaris; coryncbactc- 
rium pseudodiphthcricum 

2.3 

4 

None 

12 

49-4004 

41 -M 

I'orchcad 

Beta hemolytic streptococcus; 
non-hcmolytic coagulase pos- 
itive staphylococcus aureus 

I .0 

3 

None 

13 

49-4236 

34-F 

Toe 

Coagulase positive non-hcmo- 
lytic staphylococcus aureus 

3.6 

6 

None 

14 

49-4013 

26-M 

Ankle 

No culture obtainable 

2.0 

5 

None 

15 

49-1496 

51-M 

Face 

Gamma streptococcus; sta- 
phylococcus albus 

7.5 

10 

Incision and drainage 
cervical abscess third 
daj' of therapy 

16 

49-4003 

30-M 

Foot 

No culture obtainable 

6.7 

1 1 1 

None 

17 

49-4302 

30-M 

Hand 

Beta hemolytic streptococcus; 
coagulase positive beta he- 
molytic staphylococcus au- 
reus 

5.2 

7 

None 

18 

49-475 1 

21-M 

Wrist 

No culture obtainable 

2.8 

4 

None 

■9 

49-4822 

28-M 

Elbow 

Beta hemolytic streptococcus; 
staphylococcus albus 

2.4 

4 

None 

20 

49-4806 

24-M 

Foot 

No culture obtainable 

2.4 

4 

None 

21 

49-4981 

26-M 

Hand 

Beta hemolytic streptococcus; 
coagulase positive beta hemo- 
lytic staphvlococcus aureus 

2.4 

6 

None 

22 

49-5699 

40-F 

Face 

No culture obtainable 

5-2 

0 

None 

23 

49-62 1 1 

24-M 

Neck 1 

Culture negative 

2.8 

6 

Aspiration second day 
of therapy 

24 

49-7014 

74-M 

Hand Forearm 

Paracolon bacillus; staphj'lo- 
coccus albus, corynebacte- 
rium pseudodiphthcricum; 
anaerobic streptococcus 

6.0 

9 

Incision and drainage 
of hand seventh day 
of therapy 

25 

49-8502 

25-M 

Foot 

No culture obtainable 

4-5 

6 

Bleb broke third day 
of therapy 

26 

49-8842 

65-M 

Face 

Aerobacter acrogenes; micro- 
coccus sp. 

8.1 

1 I 

Incision and drainage 
first day of therapj' 

27 

49-8592 

17-F 

Thigh 

No culture obtainable 

12.0 

16 

None 

28 

49-8880 

54-M 

Leg 

No culture obtainable 

8.5 

1 I 

None 

29 

49-8486 

44-F 

Leg 

No culture obtainable 

10.6 

13 

None 


* Series Case No. 9 from Post Graduate Hospital. 


American Journal of Surgery 







Logan et al. — Aureomycin in Tissue Infections 
Table ii {Continued) 


231 


■ 

Series 

No. 

Case 

No. 

Age 

and 

Sex 

Site 

Organism Isolated 

Total 

Dose 

in 

Gm. 

Days 

under 

Treat- 

ment 

Surgery 

30 

49-8181 

57 -F 

Leg 

Hemolytic and non-hemolytic 
staphylococcus albus; Cory- 
nebacterium pseudodiphthe- 
ricum 

7-5 

10 

None 

31 

49-7999 

49 -F 

Lip 

Beta hemolytic streptococcus; 
non-hemolytic staphylococ- 
cus albus; micrococcus sp. 

5-2 

7 

None 

32 

49-8534 

29-M 

Finger 

No culture obtainable 

5-5 

1 I 

None 

33 

49-8092 

41-M 

Hand 

Staphylococcus albus; gamma 
streptococcus 

9 7 

13 

None 

34 

49-8099 

32-M 

Foot I 

Coagulase positive hemolytic; 
staphylococcus aureus; beta 
hemolytic streptococcus 

8.0 

8 

None 

35 

49-9285 

17-M 

Thigh 

lischerichia coli 

10.3 

14 

None 

36 

49-8447 

15-M 

Face 

Coagulase positive hemolytic; 
staphylococcus aureus 

13-5 

18 

None 

37 

49-9274 

41-M 

Hand 

No culture obtainable 

3.0 

4 

None 

38 

49-4698 

25-F 

Retroperitoneal 

Escherichia coli; aerobacter 
aerogenes; beta hemolytic 
streptococcus; gamma strep- 
tococcus; corynebacterium 
pseudodiphthericum 

20.0 

20 

None 

39 

49-8323 

39 -F 

Knee 

Beta hemolytic streptococcus 

1 I .0 

I T 

Incision and drainage 
first day of therapy 

40 

49-8303 

39 -M 

Periurethral 

Staphylococcus albus; coryne- 
bacterium pseudodiphtheri- 
cum 

10 0 

10 

Incision and drainage 
second day of therapy 

41 

49-3230 

40-M 

Paronychia 
of toe 

Hemolytic and non-hemolytic; 
staphylococcus albus; gam- 
ma streptococcus 

6.6 

I 1 

Removed nail first day 
of therapy 

42 

49-566 

6-F 

Scalp 

Beta hemolytic streptococcus 

n .2 

15 

Ruptured spontane- 
ously two days before 
therapy 


ing within the first twenty-four hours. 
Response was so prompt that surgery was 
necessary in only seven cases. The total 
dosage of aureomycin used in each case 
varied from i to 20 Gm. 

The results in these cases of cellulitis 
were uniformly excellent. All evidence of 
infection subsided promptly and steadily 
until the patients were discharged. 

The following report of a phlegmon of 
the nose, which was treated at the Post- 
Graduate Hospital, is presented through 
the courtesy of Dr. Morris Kaplan. 

Series Case No. p., T. K., a forty-six year 
old physician, was admitted to the Post- 
Graduate Hospital on January 24, 1949, with 
a phlegmon of the right nasal vestibule, edema 



Fig. I. Mean blood level curve obtained from six- 
patients receiving 250 mg. of aureomycin orally three 
times daily; * = period of aureomycin administration. 


February, ig^o 



232 


Logan et al. — Aureomycin in Tissue Infections 


of the upper lip and infraorbital region. A 
culture obtained on January 22, 1949, before 
admission to the hospital, showed staphylococci. 
Incision and drainage were performed. The 
patient was given 600,000 units of penicillin in 
oil intramuscularlj^ and 200,000 units in saline 


before hospital admission. In another 
spontaneous rupture occurred before ad- 
mission, Incision and drainage was per- 
formed in one patient after initiation of 
therapy. In the six remaining cases there 
was prompt cessation of pain after treat- 


Table III 

ISCHIORECTAL ABSCESSES 


Series 

No. 

Case 

No. 

Age 

and 

Se.x 

Site 

Organism Isolated 

Total 

Dose 

in 

Gm. 

Days 

under 

Treat- 

ment 

Surgery 

43 

49-4952 

32-F 

Perianal 

Escherichia coli; gamma 
streptococcus; paracolon 
bacillus 

6.4 

9 

Spontaneous rupture fourth 
day of therapy 

44 

49-5709 

54 -M 

Ischiorectal 

None obtained 

6.8 

I I 

Incision and drainage before 
therapy 

Spontaneous rupture before 
therapy 

45 

49-3197 

34 -M 

Ischiorectal 

Escherichia coli; staphjdo- 
coccus albus 

3-6 

4 

46 

49-3729 

33 -M 

Perianal 

None obtained 

5.0 

5 

Spontaneous rupture second 
day of therapy 

47 

49-4064 

27-F 

Perianal 

Eseherichia coli; anaerobic 
streptococcus 

3-4 

8 

Spontaneous rupture fourth 
day of therapy 

48 

49-6752 

26-M 

Ischiorectal 

1 

None obtained 

5.4 

8 

Spontaneous rupture fourth 
day of therapy 

49 

49-8497 

35 -M 

Ischiorectal 

Escherichia coli; beta hemo- 
lytic streptococcus 

6.6 

9 

Incision and drainage fourth 
day of therapy 

50 

49-8022 

22-F 

Ischiorectal 

Escherichia coli; staphylo- 
coccus albus; anaerobic 
streptococcus 

5.4 

8 

Spontaneous rupture fourth 
day of therapy 

51 

49-3197 

34 -M 

ischiorectal 

Gamma streptococcus; 
staphylococcus albus 

5-2 

7 

Spontaneous rupture third 
day of therapy 


daily. On January 26, 1949, Staphylococcus 
aureus was obtained on culture. Sensitivity 
tests showed that the organism was resistant 
to penicillin and susceptible to aureomycin. 

The patient failed to improve with penicillin 
therapy. On January 31, 1949, aureomycin was 
given orally in a dosage of 250 mg. four times a 
day. Twenty-four hours later the edema had 
subsided and on February 3, 1949, the patient 
was discharged, cured. 

ISCHIORECTAL ABSCESSES 

Nine patients with ischiorectal abscesses 
were treated with aureomycin. (Table iii.) 
Two patients gave histories of previous rec- 
tal operations for hemorrhoids or fistulas- 
in-ano. The temperature ranged between 
99° and io2°F. in all cases. 

In one case incision and drainage of an 
ischiorectal abscess had been performed 


ment with aureomycin. Spontaneous rup- 
ture of the abscesses occurred between the 
second and fifth days of therapy. The total 
dosage of oral aureomycin used varied 
from 3.4 to 6.8 'Gm. 

The patients were discharged between 
the fourth and eleventh days after ad- 
mission, with clean, granulating wounds. 
In no instance did a fistula-in-ano result. 
Only once was it necessary to incise an 
abscess. Surgery was not indicated in the 
other cases. 

INFECTED LEG ULCERS 

Five patients were treated in this group. 
(Table iv.) Four of these patients were 
diabetics who had chronic ulcers of the 
feet, with surrounding cellulitis. In two 
instances there was also gangrene of the 

American Journal of Surgery 








233 


Logan et al. — ^Aureomycin in Tissue Infections 


toes. Fluctuant abscesses of the foot were 
incised in two patients at the onset of 
aureomycin therapy. Beta hemolytic strep- 
tococci were the most frequent primary 
infecting organisms. The diabetes in these 
patients was properly controlled with 
treatment. 


patients were acutely ill on admission, with 
enlarged, tender lymph nodes, leukocytosis 
and a temperature range between ioo° and 
I04°F. 

In two cases the nodular masses were 
fluctuant and incision and drainage were 
performed at the outset. In another case 


Table iv 

INFECTED LEG ULCERS 


Series 

No. 

Case 

No. 

Age 

and 

Sex 

Site 

Organism Isolated 

Total 

Dose 

in 

Gm. 

Days 
under j 
1 Treat- 
ment ) 

Surgery 

52 

40-861 

59-F 

Toe 

Beta hemolytic streptococcus 

1 

13-3 

1 

20 1 

None 

53 

48-23606 

38-F 

Foot 

i 

Pseudomonas aeruginosa; non- 
hemolytic staphylococcus albus 

16.5 

25 

Incision and drainage 
at onset of therapy' 

54 

49-476 

49-F 

Toe 

Beta hemolytic streptococcus; co- 
agulase positive hemol3rtic staphy- 
lococcus albus 

24.9 

34 j 

1 

Incision and drainage 
at onset of therapy 

55 

49-40 I I 

56-M 

Leg 

Foot 

Escherichia coli; beta hemolytic 
streptococcus; proteus vulgaris; 
pseudomonas aeruginosa; micro- 
coccus sp. 

9.9 

15 

None 

56 

49-4683 

55-M 

Ankle 

Proteus vulgaris; pseudomonas 
aeruginosa; gamma streptococcus 

8.7 

12 ^ 

None 


Table v 

LYMPHADENITIS 


Series 

No. 

Case 

No. 

Age 

and 

Sex 

Site 

Organism Isolated 

Total 

Dose 

in 

Gm. 

Days 

under 

Treat- 

ment 

Surgery 

57 

1 

49-2579 

49-M 

Supraclavicular 

Culture negative 

1 I I .0 

15 

Aspiration second day 
of therapy 

58 

49-1136 

38-F 

Submental 

i Culture negative 

1 

1 

15.9 

25 

1 Aspiration seventh day 

1 of therapy 

59 

49-41 r6 

34-M 1 

! 

Submental 

Anaerobic streptococcus; 
staphylococcus albus; mi- 
crococcus sp. 1 

7.0 

10 

Incision and drainage 
fourth day of therapy 

60 

49-4292 

18-M 

Cervical 

Beta hemolytic streptococ- 
cus; coagulase positive he- 
molytic staphylococcus 
aureus 

2.4 

4 

1 Incision and drainage 
first day of therapy 

61 

* 

45-F 

Axillary' 

Staphylococcus albus 

1-5 

2 

None 


Patient not admitted 






Intravenous and oral aureomycin cured 
these patients of their infections. 

LYMPHADENITIS 

Five patients with acute bacterial lym- 
phadenitis were treated. (Table v.) These 

February, 1950 


an axillary abscess ruptured prior to ad- 
mission and the culture showed Staphylo- 
coccus albus. Two other patients received 
treatment before suppuration. Aspiration 
was performed in two instances and the 
fluid obtained was sterile. 




234 


Logan et al. — Aureomycin in Tissue Infections 


The various infections were brought 
under control within three or four days 
but non-tender, palpable nodes persisted 
in some cases as long as twenty-five days. 
In all cases there was prompt, progressive 
reduction of temperature, pain and toxemia. 



patients receiving 300 mg. of aureomycin intraven- 
ously twice daily; * = period of aureomycin ad- 
ministration. 

TRAUMATIC CASES 

In view of their clinical significance and 
response to aureomycin the following cases 
are briefly described: 

Human Bite oj the Hand. i. A fifty-year 
old policeman (Series Case No. 62, Hospital 
Case No. 49-5043) was admitted with a history 
of having received a human bite on the right 
hand eight days previously. The injurj"^ was 
followed by pain and swelling of the entire 
right hand and forearm. Six days before admis- 
sion his physician administered 600,000 units 
of penicillin in oil; this was repeated at two-day 
intervals. 

On admission the dorsum of the hand and 
forearm was markedly tender, red and swollen 
and there was an ulceration about 3 cm. in 
diameter over the head of the third metacarpal 
bone. The base of the lesion was gray and 
necrotic and the extensor tendon to the finger 
could be seen. Flexion of the involved finger 
was absent. The organisms isolated from the 
ulcer were Streptococcus viridans, gamma 
streptococcus and Micrococcus sp. 

Intravenous aureomycin, 500 mg., was given 
twice daily for two days. At this time the 


swelling was definitely reduced and the tem- 
perature had returned to normal. The wound 
was reduced to i cm. in diameter and was clean 
and granulating, with only slight drainage. 
Beginning on the third da}" the patient was 
given oral aureomycin, 250 mg., three times a 
da}". After eight days the patient was dis- 
charged with the ulceration healed and com- 
plete motion of the finger. 

2. A forty-one year old male (Series Case 
No. 63, Hospital Case No. 49-9274) was bitten 
on his left hand three days before admission. 
At the time of hospitalization a laceration 
surrounded by a 3 by 4 cm. area of swelling 
and tenderness was present over the thenar 
eminence. Lymphangitis was present, e.xtending 
to the axilla where a tender lymph node meas- 
uring I by 2 cm. was palpable. No culture was 
obtained. 

The patient was given 250 mg. of aureomycin 
orally twice daily. Two days after the institu- 
tion of therapy the lymphangitis had disap- 
peared. The patient was discharged as cured 
five days later. 

The immediate and effective control of 
infection in these two cases of human bite is 
noteworthy. 

Traumatic Amputation oJ the Thigh. A 
forty-one' year old male (Series Case No. 64, 
Hospital Case No. 48-23699) who had been 
struck by a truck was admitted in shock. He 
had a compound fracture in the upper third of 
the left femur, with avulsion of the soft tissues. 
The white blood cell count was 10,000, with 
80 per cent polymorphonuclear leukoc}"tes, 
red blood cell count 2,000,000 and hemoglobin 
8 Cm. Cultures revealed Clostridium per- 
fringens, beta hemolytic streptococci, and 
Escherichia coli. 

Whole blood transfusions and plasma in- 
fusions were given pre- and postoperatively. 
The amputation was completed and after 
extensive debridement of the soft tissues the 
wound was packed with gauze and the stump 
injected with penicillin. Large doses of peni- 
cillin and sulfadiazine were administered daily. 
The patient’s temperature remained at about 
ioi°F. and there was profuse foul drainage from 
the stump. Four days after admission the 
stump was again debrided and repacked. 
Penicillin and sulfadiazine therapy was still 
maintained but the discharge was not reduced. 

Eleven days after admission when the pa- 
tient’s temperature had risen to I 04 °F. oral 

American Journal oJ Surgery' 


235 


Logan et al. — Aureomycin in Tissue Infections 


aureomycin, 500 mg. twice daily, was given 
in addition to penicillin and sulfadiazine. On 
the following day the temperature dropped to 
normal for the first time since admission. At 
this time the combined penicillin and sulfadia- 
zine therapy was discontinued in favor of 
aureomycin alone. This was attended by a 
definite gradual reduction of the foul odor and 
slough from the stump. 

Fourteen days after admission the dosage of 
aureomycin was reduced to 250 mg. twice daily. 
One month after admission aureomycin was 
discontinued for a period of five days, during 
which time operative revision was performed. 
The patient’s temperature rose postoperatively 
to i05°F. Intravenous aureomycin, 400 mg., 
was given for three days. The temperature be- 
came normal and remained so until the patient 
was discharged six weeks after admission. 

Traumatic Amputation oj the Leg. A forty- 
nine year old male (Series Case No. 65, Hospital 
Case No. 49-7361) who had been struck by a 
car was admitted to the hospital with a trau- 
matic amputation of the right leg 2 inches 
below the knee joint. The patient was in shock 
and control measures were instituted. His 
temperature was ioi.6°f. and tetanus and gas 
gangrene antisera were given. Culture re- 
vealed Aerobacter aerogenes and anaerobic 
streptococci. 

The leg was disarticulated at the knee joint 
and the stump was left open and packed. Oral 
aureomycin, 250 mg,, was given four times 
daily. Six days after admission his temperature 
became normal and remained so. Twelve days 
after admission the stump was clean, at which 
time it was revised and closed. Healing by 
first intention resulted. 

These two cases indicate that aureomy- 
cin may be used either prophylactically or 
for the control of established infection in 
traumatic amputations. 

Stab Wound oj the Thigh. A thirty-nine 
year old ^ale (Series Case No. 66, Hospital 
Case No. 48-1191) was admitted with deep 
lacerations of the left thigh and buttock sus- 
tained thirty minutes before. The laceration 
measured 12 by 6 cm. and extended to the 
femur on the lateral aspect of the thigh. A 
smaller laceration was present on the right 
buttock, exposing the gluteal muscles. 

The wounds were debrided and closed. Gas 
gangrene and tetanus antisera were given. 

February'', ig^o 


Twenty mg. of aureomycin was given intra- 
muscularly daily. The wound healed per 
primam and the patient was discharged nine 
days later. 

Lacerated Wound of the Neck and Trachea. 
An adult male (Series Case No. 67, Hospital 
Case No. 49-7256) was admitted with a severe 
laceration of the anterior triangle of the neck 
on the right side. A 2 cm. laceration was present 
in the trachea. After the insertion of a tracheo- 
tomy tube the wound was explored for major 
hemorrhage and then packed. Cultures taken 
on admission revealed A. aerogenes. Staph, 
albus and anaerobic streptococci. 

Oral aureomycin, in 250 mg. doses, was given 
three times daily. At the end of one week there 
was no gross evidence of infection. The wound 
was granulating and the tracheotomy tube was 
removed. Three weeks after admission the 
patient was discharged, cured. 

These two patients with deep, lacerated 
wounds responded well to prophylactic aureo- 
mycin therapy. 

Thrombophlebitis of the Axillary Vein and 
Subclavian Vein following Laceration of the 
Hand. This case is presented through 
the courtesy of Dr. David J. Graubard. 
The patient (Series Case No, 68) was seen 
by one of the authors (L. T. W.) in con- 
sultation at Hunts Point Hospital on 
March 3, 1949. 

On July 23, 1948, A. B., a forty-nine year 
old male, sustained a laceration of his left index 
finger. Several days later lymphangitis of the 
arm developed. He w^as hospitalized at the 
Wade Hospital, Brooklyn, and subsequently 
at the Manhattan General Hospital, in which 
institutions he was treated with penicillin, 
streptomycin and sulfadiazine. During this 
period chronic lymphadema of the left hand 
and wrist, secondary causalgia of the hand, 
subdeltoid bursitis and periarthritis of the 
elbow joint developed. There was loss of 
motion of the left arm, shoulder, hand and 
fingers. 

Various procedures were carried out for the 
relief of pain and to increase the mobility of 
the affected parts but without avail. On 
December 28, 1948, there was a return of the 
swelling of the left arm and hand, with con- 
siderable inflammation. There was no response 
to chemotherapy. Between January 9 and 
January 13, 1949, the patient was hospitalized 



236 


Logan et al. — Aureomycin in Tissue Infections 


at St. Clare’s Hospital, with signs and symp- 
toms of coronary thrombosis. On January 18, 
1949, there was an exacerbation of the cellulitis 
of the left arm involving the shoulder, the 
acromioclavicular joint and part of the anterior 
left chest wall. 

At this time the diagnosis was thrombo- 
phlebitis of a chronic, low grade type following 
laceration of the finger. It was believed that 
the thrombophlebitis had extended into the 
left subclavian vein and some of its tributaries. 
Although the patient was afebrile, he was 
acutely ill during this period. 

On February 21, 1949, the left olecranon 
bursa was aspirated and cultures made of the 
fluid. An organism was isolated which, on some 
media, frequently presented the morphology 
of a staphylococcus but on other media, 
especially liquids, was found to have the 
characteristics of a pleomorphic diphtheroid 
bacillus. On February 25, 1949, a second 
culture from the same area showed Staph, 
albus. Sensitivity tests showed that both t3'pes 
of organisms were resistant to penicillin and 
sulfonamides and only slightly susceptible to 
streptomycin. However, both were susceptible 
to low concentrations of aureomycin. 

Therefore, on March 18, 1949, the patient 
was given oral aureomycin and improvement 
in his condition was noted. However, after a 
few days the drug caused slight nausea and 
was discontinued. 

On March 30, 1949, the patient again pre- 
sented a swollen and tender left arm. The 
swelling involved the shoulder girdle and he 
was unable to flex his forearm. A small lymph 
node which was very tender was palpated in 
the supraspinous fossa. 

At this time aureomycin was resumed in a 
dosage of i Gm. daily by the intravenous route. 
Pain and edema decreased promptly. The 
patient’s general condition improved and he 
was able to go home April 18, 1949. When last 
seen there was no recurrence of symptoms and 
there was noted a gradual return of motion. 

GAS GANGRENE INFECTIONS 

In this group of four cases in two in- 
stances (Series Cases No. 69 and 70, 
Hospital No. 48-21861 and 48-20146) gas 
gangrene developed postoperatively in 
lower extremity amputations in spite of the 
fact that both patients were receiving 
penicillin. The other two patients (Series 


Cases No. 71 and 72) who had gas gangrene 
of the upper extremity had also received 
penicillin. 

CL perfringens was isolated from three 
of the four patients, thus proving the 
diagnosis of gas gangrene. Secondary in- 
vaders included Proteus vulgaris, anae- 
robic streptococci, Esch. coli, gamma 
streptococci and hemolytic staphylococcus 
albus. In the other case (Series Case No. 
69), which was one of gas gangrene of the 
stump of a mid-leg amputation, no cultures 
were obtained. 

Each of the lower extremity infections 
was reamputated at a higher level after the 
diagnosis of gas gangrene had been estab- 
lished. They were treated with intravenous 
aureomycin. 

In one patient, a sixty-one year old female 
(Series Case No. 69), marked crepitus of the 
soft tissues developed on the second daj' fol- 
lowing a mid-leg amputation. Despite aureo- 
mycin therapy she followed a downhill course 
and expired. Autopsi’’ showed massive pul- 
monary consolidation, pleural effusion, arterio- 
sclerotic and hj'pertensive heart disease and 
gangrene of the amputated stump. In this case 
it is possible that our dose of aureomycin was 
inadequate, particularly in view of the massive 
pulmonary consolidation wdilch developed. 

The other case (Series Case No. 70) of gas 
gangrene following mid-leg amputation showed 
definite improvement under aureomjHn treat- 
ment three daj^s after stump revision. During 
this period the patient received intravenous 
aureomycin followed by oral aureomycin for 
thirtj"-five daj^s. At this time there was no 
further evidence of infection of the stump. 

Two patients (Series Cases No. 71 and 72, 
Hospital No. 48-19194 and 48-12834) had gas 
gangrene of the upper extremity. One was a 
severe asthmatic and the other a severe dia- 
betic. Both had received large doses of peni- 
cillin for treatment of extensive cellulitis of the 
arm. Incisions and debridement were performed 
prior to aureomycin therapy. The patients 
were treated with aureomycin for the entire 
postoperative period and were discharged from 
the hospital, cured, approximately three weeks 
after operation. 

The total dosage of aureomycin in these 
four cases ranged from 7 to 27 Gm. Aureo- 

American Journal oj Surgery 



237 


Logan et al. — Aureomycin in Tissue Infections 


mycin has a definite place in the treatment 
of these infections in addition to adequate 
surgery. 

CARBUNCLES 

Two patients (Series Cases No. 73 and 
74, Hospital No. 48-23891 and 49-884), 
ages thirty-nine and sixty-seven years, 
respectively, were treated in this group. 
One patient had severe associated diabetes. 
Both had exquisitely tender carbuncles 
approximately 10 cm. in diameter. The 
induration covered a still larger area. In 
the central area there were numerous tiny 
focal points from which pus drained. 
Cultures in both cases revealed gamma 
streptococci, coagulase positive beta hemo- 
lytic staphylococcus aureus and Sarcina 
lutea. 

One patient was treated with oral 
aureomycin. On the second day the car- 
buncle had become more localized and 
fluctuant. Three days later under ethyl 
chloride anesthesia while in bed a i inch 
cruciate incision was made which released 
a moderate amount of pus. The patient 
made an uneventful recovery. 

In the second case, no surgery was 
necessary. 

SIGNIFICANT MISCELLANEOUS CASES 

The following cases were of sufficient 
interest to warrant brief abstracts: 

Paracolon Bacillus Bacteremia. A fifty year 
old female (Series Case No. 75, Hospital Case 
No. 49-788) complaining of fever and weakness 
was admitted on January 10, 1949. Prior to 
admission she had been in another hospital for 
six weeks where no causes for her fever could 
be found. Urine and blood cultures, agglutina- 
tion tests and blood smears for malaria were 
all negative as were x-rays. The diagnosis was 
possible subacute bacterial endocarditis. Four 
million units of penicillin had been given daily 
for ten days. The fever continued and rose as 
high as I04°F. 

On admission to Harlem Hospital the tem- 
perature was loi^F. Laboratory studies showed 
secondary anemia. Blood cultures on the day 
of admission and on the following day were 
positive for paracolon bacillus. 

Februar^r^ ig^o 


In the week following admission the patient 
received two transfusions of 500 cc. of whole 
blood. Beginning on her twelfth hospital day 
she was treated with 750 mg. of oral aureo- 
mycin daily. The fever continued until the 
eighteenth day when the patient had a chill 
and fever of io3°f. following a transfusion. 

Beginning on the nineteenth day after ad- 
mission 200 mg. of intravenous aureomycin 
were given twice daily. By the fourth day of 
this therapy her temperature had become 
normal and remained so. The patient was 
discharged as cured at the end of one month. 
When seen three months later she was entirely 
well. 

A. Aerogenes Bacteremia with Meningitis. 
A four month old male infant (Series Case No. 
76, Hospital Case No. 49-6640) was admitted 
on April 6, 1949. The mother reported the 
presence of fever, anorexia and loss of weight 
during the previous two weeks. On admission 
his temperature was i03°f. 

Physical examination revealed an acutely 
ill infant. The anterior fontanel was bulging 
and nuchal rigidity was present. There were 
hyperactive reflexes and the extremities were 
spastic. The white blood cell count was 12,000, 
with 70 per cent polymorphonuclear leukocytes. 
The spinal fluid was cloudy and contained 460 
white blood cells with 85 per cent polymorpho- 
nuclear leukocytes. Cultures of the blood 
and spinal fluid were positive for type 7 
pneumococcus. 

Penicillin, 100,000 units, was given every 
three hours, combined with sulfadiazine, 3% 
gr., every four hours. Intratibial infusions were 
given daily. Two days after admission the 
infant’s temperature returned to normal and 
remained so for twelve days, during which 
time the blood and spinal fluid cultures were 
negative. 

Fifteen days after admission the temperature 
rose to io 4 °f. A small pustule was seen at the 
site of the intratibial infusion in the left leg. 
The leg became progressively edematous and 
tender. Twenty days after admission cultures 
from the leg, blood and spinal fluid were posi- 
tive for A. aerogenes. 

The patient was given penicillin and sulfa- 
diazone until May 4, 1949. During this period 
his temperature fluctuated between 103° and 
i04°F. Aureomycin, 125 mg. orally, was then 
given every six hours. 

On the following day the temperature de- 



238 


Logan et al. — Aureomycin in Tissue Infections 


creased to ioo°f. and three days later was 
normal and remained so. On the fifth day of 
aureomycin therapy eultures from the wound, 
blood and spinal fluid were negative. The dis- 
eharge, swelling and tenderness of the leg 
disappeared and after eight days of aureomycin 
therapy the patient left the hospital, cured. 

Rat-bite Fever. This patient (Series Case 
No. 77) was treated at the Mount Sinai 
Hospital. This report is presented through 
the courtesy of Dr. Samuel Karelitz. One 
of the authors (A. P.) cooperated on this 
case. 

P. F., a seven and a half year old male, was 
admitted in October, 1947, complaining of a 
cough and fever of three da3"s’ duration. At the 
age of three j^ears he was bitten by an animal 
during a Florida hurricane, following which he 
had recurrent attacks of fever and the appear- 
ance of a macular rash. In 1946 he had suffered 
a head injurj^ which resulted in left hemiplegia. 

Physical examination on admission showed 
a chronically ill, poorlj^ nourished child with 
evidence of pansinusitis and pneumonitis in 
both lower lung fields. There was a brown, 
crusted eschar 3 sq. cm. large on the right fore- 
head; a similar lesion was noted on the left 
buttock at the site of an old penicillin abscess. 

Examination of the skin lesions did not show 
any unusual bacteria, or fungi. The laboratory 
studies revealed leukopenia and cultures from 
the ear, nose and throat showed Staph, albus. 
However, blood cultures revealed Spirillum 
minus. 

The patient was maintained on high doses of 
penicillin but the blood cultures remained 
positive for S. minus. For eight months he 
received streptomycin, mapharsen and sulfa- 
diazine without response. The dosage of 
streptomycin was increased and the patient was 
discharged after two blood cultures were 
reported negative. 

Three weeks after discharge blood cultures 
again showed the presence of S. minus and the 
patient was readmitted to the hospital. The 
organism at this time was found to be sus- 
ceptible to Ho of I unit of streptomycin, 2 
micrograms of aureomycin and 4 micrograms 
of chlordmycetin. 

On December 29, 1948, oral aureomycin, 500 
mg. orally, was given every six hours and con- 
tinued for ten days. The drug was then dis- 
continued for ten days and the treatment re- 


instituted, using the intravenous route, 600 
mg. in divided doses daily, for three daj's. Oral 
administration of 500 mg. every six hours was 
then resumed. Thereafter weekly blood cultures 
were negative. 

At the time of discharge the patient was re- 
ceiving decreasing amounts of aureomycin. His 
blood cultures continued to be negative but his 
nasal discharge and eoughing increased. Main- 
tenance dosage was raised to two capsules of 
250 mg. dailj" to control the respiratory 
infection. 

From Maj' 4, 1949, to June 15, 1949, he was 
given no medication. During this period the 
blood cultures remained negative. 

The patient was last seen on August i, 1949, 
at which time the blood culture was negative 
and he was asij'mptomatic. 

This case is of interest because the 
patient did not respond to intensive peni- 
cillin or streptomycin therapy. Dragisic^^ 
reported a case of S. minus infection cured 
with 700,000 units of penicillin. Salmon^® 
reported a patient cured with 10,000 units 
of penicillin given intramuscularly every 
three hours for seven daj's, Tlie S. minus 
infection reported here was resistant to 
penicillin but responded to aureomjmin. 

Urinary Extravasation. A thirtjf-three year 
old male (Series Case No. 78, Hospital Case 
No. 48-5834) was admitted to the hospital on 
March 21, 1948, with extensive urinarj'- extra- 
vasation following dilatation of a urethral 
stricture. 

Multiple incisions were made in the shaft of 
the penis and scrotum with the release of a 
purulent exudate. Suprapubic cystostomj^ was 
performed. Culture of the exudate revealed 
Esch. coli, gamma streptococci and paracolon 
bacilli. 

Aureomj'cin, 20 mg. ' intramuscularly, ^yas 
given daily for twentj'-five days during which 
time there was gradual healing of the extensive 
sloughing wounds. 

Furunculosis. E. D., a thirty-two year old 
policeman (Series Case No. 79) with multiple 
f^uruncles of the trunk and arms, was seen 
privately by one of the authors (L. T. W.) on 
September i, 1948. He had been a victim of 
furunculosis for several years in the past. In 
1947 he was treated at Harlem Hospital for one 
week, receiving massive doses of penicillin. 

American Journal oj Surgery 


Logan et al. — Aureomycin in Tissue Infections 


239 


On physical examination there were multi- 
ple, tender, raised pustules on the trunk and 
face varying from i to 10 cm. in diameter. They 
were particularly extensive on the buttocks 
where they required dressings and prevented 
his sitting down. Cultures revealed coagulase 
positive staphylococcus aureus. 

Penicillin, 600,000 units intramuscularly, 
was given daily for one week but the lesions 
continued to spread to the entire body. Those 
on the buttocks measured 7 cm., with marked 
surrounding edema. 

Penicillin was discontinued and aureomycin, 
40 mg. intramuscularly, was given daily for 
three days. After two days there was definite 
relief of the severe pain which had previously 
required narcotics. There was a rapid clearing 
of the draining lesions and the patient returned 
to work in one week. 

Pyoderma 0/ the Scalp. This patient (Series 
Case No. 80, Hospital Case No. 49-566) was a 
six year old male child with pyoderma of the 
entire scalp. Cultures revealed beta hemolytic 
streptococci. 

Green soap shampoos and aureomycin given 
orally, 250 mg. twice daily, cleared the lesions 
and the patient was discharged, cured, on the 
tenth day. 

Erysipelas of the Face. This sixty-six year 
old female (Series Case No. 81, Hospital Case 
No. 49-10597) was admitted with a severe 
erysipelas of the face. She had been treated 
previously for two days with penicillin but con- 
tinued to have fever. The edema closed both 
eyes. 

She responded to aureomycin given orally in 
two days and was discharged from the hospital 
on the third day, cured. 

Postpartum Mastitis. This patient, a twenty 
year old female, was nine months postpartum 
(Series Case No. 82,Hospital Case No. 49-4739). 
She was still feeding her child by breast when 
fever, pain and swelling developed in the 
breasts. 

On admission her temperature was i03°f. 
and both breasts were engorged. There was a 
red, tender, hot area surrounding the nipple 
of the right breast. The white blood cell count 
was 13,000, with 86 per cent polymorpho- 
nuclear leukocytes. 

The patient was given 200 mg. of aureomycin 
intravenously twice daily for two days, at 
which time her temperature returned to nor- 
mal. A breast binder was applied and on the 
third day oral aureomycin was started. 

February, 1950 


There was rapid disappearance of all signs of 
infection and the patient was discharged after 
three days of aureomycin therapy. 

COMMENTS 

The treatment with aureomycin of 
eighty-two patients with soft tissue infec- 
tions has established its value as a thera- 
peutic agent. In only one case in this series 
did the infection become more severe in 
spite of aureomycin therapy. 

As expected, various types of organisms 
were isolated from the cases reported, with 
staphylococci and beta hemolytic strepto- 
cocci predominating. These two organisms 
were the primary inciting agents of the 
vast majority of acute, localized or spread- 
ing infections such as cellulitis, carbuncles, 
furuncles and lymphadenitis. Gram-posi- 
tive bacilli were the etiologic agents in only 
one type of infection, gas gangrene, where- 
as gram-negative bacilli were involved 
mainly in abscesses of, or near, the rectum. 
Two cases of septicemia due to gram- 
negative bacilli are reported. Various other 
micro-organisms such as Corynebacterium 
pseudodiphthericum, Pr, vulgaris. Pseudo- 
monas aeruginosa, S. lutea, M. sp., etc., 
were at times isolated in the original 
culture from these infections. For the most 
part, however, they were considered to be 
secondary invaders. 

Repeated cultures were obtained from 
many of the patients at intervals after the 
institution of aureomycin therapy. In 
many cases the infecting organisms could 
still be isolated as long as three or four 
days after the initiation of therapy even 
though the patient was greatly improved 
clinically. This is probably explained in 
part by the fact that aureomycin in the 
concentrations employed exerts mainly a 
bacteriostatic effect. As the course of the 
disease progressed, many secondary in- 
vaders could be cultured from the diseased 
site; but these organisms, including Pr. 
vulgaris, Ps. aeruginosa, A. aerogenes and 
Esch. coli, apparently added little if any- 
thing to the pre-existing infection, nor did 
they perceptibly delay healing. It is quite 



240 


Logan et al. — Aureomycin in Tissue Infections 


unlikely that these secondar}^ organisms 
play any definite role in local infections 
that are open and draining. 

It is to be noted that in the majority of 
cases only one or two species of bacteria 
were found initially. In only one case were 
more than four species found. The only 
negative cultures obtained were from 
closed Infections from which fluid was 
aspirated and cultured. 

Most of the patients in this study 
received either 300 mg. of intravenous 
aureomycin twice daily or 250 mg. of oral 
aureomycin three times daily. When given 
intravenously the drug was administered 
as an infusion in 500 cc. of 5 per cent 
glucose in distilled water. The infusion 
was adjusted so that the total dosage was 
administered within one hour. 

The clinical effectiveness of aureomycin 
against various gram-positive and gram- 
negative bacteria is corroborated by 
laboratory studies which correlate the 
aureomycin blood level (Figures i and 2) 
with the in vitro sensitivity of these 
organisms (Table vi).* Although a higher 
level is maintained for the most part by 
the intravenous route, the sensitivity re- 
sults suggest that the blood concentration 
of aureomycin resulting from the oral 
administration of the drug is sufficient to 
control most of those bacteria which were 
subjected to study. This fact was borne 
out clinically. On the whole our results 
were comparable whether aureomycin was 
given intravenously or orally. 

Table vi shows that in general different 
strains of the same organism are inhibited 
by the same, or nearly the same, concen- 
tration of aureomycin. Also, there is 
apparently no increase in resistance to 
aureomycin in instances in which, pre- 
sumably, the same organism was isolated 
more than once from the same patient. 

Sensitivity tests were read at three 
intervals because aureomycin tends to 
deteriorate in the medium used. Therefore, 

* By kindness of Mr. A. C. Dornbush and Mr. E. 
Pelcak of the Lederle Laboratories, American Cyanamid 
Company, Pearl River, New York. 


the organisms generally grew in higher 
concentrations of the drug at twenty-four 
hours than they did at four or eight hours. 
One point to be stressed is the fact that an 
organism sheltered in an isolated pocket 
of tissue .without adequate blood supply 
may not be readily eradicated even though 
it may be sensitive to that drug both in 
vitro and in vivo. 

Additional sensitivity tests showed that 
the S. minus organism isolated from a case 
of rat-bite fever (Series Case No. 77) was 
inhibited by 2 micrograms of aureomycin 
per ml. while a Staph, albus and a C. 
pseudodiphthericum isolated from an ex- 
tensive cellulitis of the arm (Series Case 
No. 24) were sensitive to 2 to 5 micrograms 
of aureomycin per ml. 

No uncontrollable toxic reactions to the 
drug were observed. There were a few 
cases of nausea and vomiting during the 
use of oral aureomycin hydrochloride. 
However, oral treatment with aureomycin 
base did not provoke any gastrointestinal 
symptoms. 

A chemical phlebitis occurred in ap- 
proximately 1 5 to 20 per cent of our cases 
in which aureomycin was administered 
intravenously. This phlebitis was mild and 
subsided in a few days. In general it ma}^ 
be stated that the larger the dose ad- 
ministered intravenously the greater the 
possibility of phlebitis. Also, the chance 
of a chemical phlebitis developing is pro- 
portionate to the number of injections 
received. In over 1,000 injections of aureo- 
mycin no embolism has occurred and the 
only possible harm has been the occlusion 
of the vein. Since we have changed from 
the use of sterile distilled water to the use 
of a leucine buffer as a diluent, the phlebi- 
tis has been eliminated. 

In respect to the specific infections 
treated the following facts were noted: 

In all patients with cellulitis treated 
before actual necrosis and pus formation 
the infection subsided promptly. It did not 
in any case proceed to fluctuation. 

Most of our cases of ischiorectal absces- 
ses ruptured spontaneously. In others 

American Journal of Surgery 



241 


Logan et al. — ^Aureomycin in Tissue Infections 


surgical intervention was indicated. In all 
cases there was a definite reduction of 
systemic evidence of infection upon treat- 
ment. With the use of aureomycin rectal 
surgery can now be done in many in- 


Four cases of gas gangrene infections 
are reported. Excellent results were ob- 
tained in three of these clostridial infec- 
tions. In the fourth case (Series Case No. 
69) in which the patient was senile and had 


Table vi 

IN VITRO SENSITIVITY OF BACTERIA TO AUREOMYCIN 


Series 

No. 

Case No. 

Date 

Isolated 

Organism Isolated 

Micrograms of Aureomycin 
per ml. Causing Complete 
Inhibition of Visible Growth 

4 Hr. 

8 Hr. 

24 Hr. 

73 

48-23891 

12/3/48 

Hemolytic coagulase positive staphylococcus 

0. 195 

0.195 

0.39 




aureus 




4 

48-23699 

i/ii /49 

Beta hemolytic streptoccus 

0.039 

0. 156 

0.312 

74 

49-884 

1/11/49 

Hemol3Tic coagulase positive staphylococcus 

0.39 

0-39 

1.56 




aureus * 




7 

49-1918 

1/26/49 

Hemolytic coagulase positive staphylococcus 

<0.097 

0.195 

1 .56 




aureus 






1/28/49 

Hemolytic coagulase positive staphylococcus 

<0.097 

<0.097 

1.56 




aureus 




54 

49-476 

2/23/49 

Pseudomonas aeruginosa 

3-12 

3.12 

12.5 



2/23/49 

Staphylococcus albus 

1 12.5 

12.5 

50.0 



2/23/49 

Beta hemolytic streptococcus 

1 0-39 

0.078 

0.156 

53 

48-2306 

2/23/49 

Pseudomonas aeruginosa 

3. 12 

6.25 

25.0 

17 1 

49-4302 

3/3/49 

Hemolytic coagulase positive staphylococcus 

<0.097 

<0.097 

0.195 




aureus 






3/3/49 

Beta hemolytic streptococcus 

0.039 

0.039 

0.312 

13 

49-4236 

3/1/49 

Coagulase positive staphylococcus aureus 

<0.097 

0.195 

0.195 

60 

49-4292 

3/3/49 

Hemolytic coagulase positive staphylococcus 

<0.097 

<0.097 

0.39 




aureus 




21 

49-498 1 

3/13/49 

Hemolytic coagulase positive staphylococcus 

<0.097 

0.195 

0.195 




aureus 





49-1365 

2/23/49 

Proteus vulgaris 

12.5 

25.0 

100.0 

♦ 

49-1507 

1/26/49 

Coagulase positive staphylococcus aureus 

<0.097 

<0.097 

0.195 



1/29/49 

Alcaligenes fecalis 

0.195 

0.78 

1 .56 

♦ 

40-2048 

1/28/49 

Escherichia coli 

0.78 

0.78 

1 .56 



1/29/49 

Escherichia coli 

0.78 

0.78 

1 .56 



1/31/49 

Escherichia coli 

0.78 

0.78 

1 .56 



2/2/49 

Pseudomonas aeruginosa 

6.25 

6.25 

25.0 



2/4/49 

Pseudomonas aeruginosa 

12.5 

12.5 

50.0 

♦ 

48-23867 

12/3/48 

Proteus vulgaris 

12.5 

12.5 

50.0 

* 

49-2743 

2/9/49 

Paracolon bacilli 

0.78 

0.78 

0.78 

* 

49-3041 

2/13/49 

Streptococcus viridans 

0.048 

0-39 

0.78 

♦ 

49-3471 

2/22/49 

Aerobacter aerogenes 

1 .56 

3.12 

6.25 



2/24/49 

Aerobacter aerogenes 

0.78 

0.78 

6.25 



2/22/49 

Klebsiella pneumoniae 

0.048 

0.097 

0. 19 



2/24/49 

Klebsiella pneumoniae 

0.048 

0.097 

0.39 


* Patients from a separate study 


stances as a definitive procedure in the 
absence of gross infection. 

It should be emphasized that the cases of 
lymphadenitis reported here are primary 
diseases and not lymphadenitis secondary 
to a constitutional disease. 

February, 1950 


extremely severe arteriosclerosis, the in- 
fection was not controlled. 

The most impressive observation of the 
carbuncle cases was the fact that within 
forty-eight hours of systemic drug therapy 
the general toxicity was relieved, the pain 



242 


Logan et al. — Aureomycin in Tissue Infections 


was reduced and the progressive nature of 
the acute inflammation ceased. One full- 
blown carbuncle receded so rapidly that 
incision was not necessary. 

Patients with the following medical 
complications were treated: diabetes, arte- 
riosclerosis, asthma, peripheral vascular 
disease and heart disease. The only instance 
in which such a complication defeated 
aureomycin therapy was the case previ- 
ously described in which severe arterio- 
sclerosis greatly reduced the blood supply 
to an infected thigh. So far as we were able 
to observe the other conditions did not 
influence the effectiveness of aureomycin 
nor did they constitute contraindications 
to the use of the drug. 

The age of the patient has not influenced 
the activity of the drug. 

Aureomycin was used effectively by the 
oral, intramuscular and intravenous routes. 
No criteria for effective dosage have been 
established. No resistance to the drug has 
developed in any organism in cases in which 
prolonged administration was necessary. 

SUMMARY 

Aureomycin was used in eighty-two 
surgical infections of the soft tissues which 
have been divided into the following 
groups: cellulitis, perirectal infections, 
peripheral ulcers, lymphadenitis, traumatic 
cases, gas gangrene infections and a mis- 
cellaneous group. 

Infections caused by a variety of gram- 
positive and gram-negative bacilli were 
successfully treated. Most of these infec- 
tions were caused by staphylococci or beta 
hemolytic streptococci. The miscellaneous 
group includes a case of bacteremia by the 
paracolon bacillus and one by S. minus. 

The age of the patients and medical 
complications have not hampered the 
activity of the drug. 

Aureomycin was used effectively by the 
oral, intramuscular and intravenous routes. 

Blood level studies and in vitro sensi- 
tivity tests have been performed and have 
confirmed the clinical results. No resist- 
ance to the drug has developed in any 


organism in cases in which prolonged ad- 
ministration was necessary. No serious 
clinical signs of toxicity have been seen 
as a result of drug administration. A 
chemical phlebitis developed in approxi- 
mately 1 5 per cent of the patients receiving 
the drug intravenously if its administra- 
tion extended two days or longer. 

In our hands aureomycin has yielded 
satisfactory results in the treatment of the 
reported infections whether used alone or 
as an adjunct to indicated surgery. It has 
appreciably shortened the clinical course 
of some infections, for example the lympha- 
denitis cases. In other infections such as 
cellulitis the usual rate of surgical interven- 
tion was markedly reduced during its use. 
In perirectal infections the use of the drug 
made early definitive surgerj^ possible by 
reducing the local infection. 

Further use of aureomycin in the field 
of soft tissue infections seems definitely 
Indicated. 

REFERENCES 

1. Duggar, B. M. Aureomycin, n. product of the eon- 

tinuing search for new antibiotics. Ann. New 
York Acad. Sc., 51: 177-181, 1948. 

2. Paine, T. F., Jr., Collins, H. S. and Finland, M. 

Laboratorj' studies with aureomycin. Ann. New 
York Acad. Sc., 51: 228-230, 1948. 

3. Little, P. A. Use of aureomycin on some experi- 

mental infections in animals. Ann. New York 
Acad. Sc., $1: 246-253, 1948. 

4. Chandler, C. A. and Bliss, M. A. In vitro studies 

with aureomycin. Ann. New York Acad. Sc., 
51 : 221-227, 1948. 

5. Price, C. W., Randall, W. A. and Welch, H. 

Bacteriological studies of aureomycin. Ann. New 
York Acad. Sc., 51:21 1-2 17, 1948. 

6. Pelcak, F. J., Metzger, W. I. and Dornbush, 

A. C. Comparative effectiveness of aureomycin, 
Chloromycetin, penicillin and streptomycin in 
vitro against various micro-organisms isolated 
from hospital patients. Harlem Hos , Bull., 2: 

47-54, 1949. , „ „ 

7. Schoenbach, E. B., Bryer, M. S. .and Long, P. H. 

The pharmacology and clinical trial of aureo- 
mycin: a preliminary report. Ann. New York 
Acad. Sc., 51: 267-279, 1948. 

8. Nichols, D. R. and Needham, C. M. Aureomycin 

in the treatment of penicillin-resistant staphy- 
lococcic bacteremia. Proc. Staff Meet., Mayo Clin., 

12:309-316,1949. _ ,, 

9. Collins, H. S., Paine, T. F., Jr. and Finland,^M. 

Clinical studies with aureomycin. Ann. New York 
Acad, ^c., 51 : 231-240, 1948. _ , 

10. Braley, a. E. and Sanders, M. Aureomycin in 

American Journal oj Surgery 


Logan et al. — Aureomycin in Tissue Infections 


ocular infections. Ann. Neiv York Acad. Sc., 51: 
280-289, 1948. 

1 1. Finland, M., Collins, H. S. and Paine, T. F., Jr. 

Aureomycin: a new antibiotic, results of labora- 
tory studies and clinical use in 100 cases of 
bacterial infections. J. A. M. A., 138: 946-949, 
1948. 

12. Collins, H. S. and Finland, M. Aureomycin 

treatment of urinary tract infections. Surg., 
Gynec. &. Obst., 89: 43-48, 1949. 

13. Wright, L. T., Metzger, W. I., Shapero, E. B., 

Carter, S. J., Schreiber, H. and Parker, 
J. W. Treatment of acute peritonitis with 
aureomycin. Am. J. Surg., 78: 15-22, 1949. 

14. Hirshfield, j. W., Buggs, C. W., Pilling, M. A., 

Bronstein, B. and O’Donnell, C. H. Strepto- 
mycin in the treatment of surgical infections; 
report of experiences with its use. Arcb. Surg., 
52: 387-402, 1946. 

15. Meleney, F. L., Altemeier, W. A., Longacre, 


M3 

A. B., Pulaski, E. J. and Zintel, H. A. The 
results of the systemic administration of the 
antibiotic, bacitracin, in surgical infections: a 
preliminary report. Ann. Surg., 128: 714-731, 
1946. 

16. Pulaski, E. J., Spicer, F. W. and Johnson, M. J. 

Streptomycin in surgical infections. Part v. 
Infections of the soft tissues. Ann. Surg., 128: 
46-56, 1948. 

17. Dragisic, B. Sodoku (Bolest Usiiged Ugriza 

Stakora) Izlijecen Penicillinom; Lijecnicki Vjes- 
nick (Lijecn Vjesn). 68: 129-132, 1946. Abstr. 
World Med., i: 325, 1947. 

18. Salmon, G. W. Symposium on chemotherapy and 

antibiotics. New Orleans M. & S. J., 100: 361- 
367, 1948. 

19. Bliss, E. A. and Chandler, C. A. In vitro studies 

of aureomycin, a new antibiotic agent. Proc. Soc. 
Exper. Biol, ef Med., 69: 467-472, 1948. 


€ 11 ^ 


Splenectomy will help almost all sufferers with so-called primary 
splenic panhematopenia in spite of the fact that the removed spleens appear 
normal and there is no definite evidence that excessive phagocytosis exists 
in these patients. Presumably the spleen has some sort of regulatory action 
on some functions and activities of the spleen and probably the reputed 
beneficial effects that follow splenectomy are explainable on this basis. 
{Richard A. Leonardo, M.D.) 


February, ig^o 



SOFT TISSUE COVER OF DEFECTS OF THE LOWER 

EXTREMITY 

Bruce C. Martin, m.d. and Raymond O. Brauer, m.d. 

Columbus, Ohio Houston, Texas 

T he problem of soft tissue idefects of the heel cord and varying degrees of anes- 
the lower extremity is largely one of thesia. In the second class are those with 
adequate cover to replace the un- marked scarring on the weight-bearing 
stable scars or to provide a suitable field surfaces with bone damage. 



lA IB IC 

Fig. I. a, b and c, healed fracture of tibia, right; a double pedicle shift was used to cover a shallow 
anteromedial defect. 


for contemplated bone or tendon surgery.^ In our experience the former group of 

In some instances the cover is adequate in patients usually has such marked changes 

itself. The operati ve scar of a secondary that walking is impossible because of severe 

closure is able to withstand normal trauma, pain or recurrent ulcer formation. In the 

however, because of the increased space latter group we have found that the pedicle 

requirements of a large bone graft, more withstands weight-bearing poorly. 

cowr is nee e . Many of these cases are now eventually 

1 here are two types oi cases m which, we . ^ . 

believe, plastic surgery is seldom indicated. ampu ation. 

In this category are those patients who ^ number of techniques are available 
have suffered severe compounding injuries to the surpon, and a method applicable to 
with marked tissue loss around the ankle the individual case at hand should e 
joint and foot. The injuries are complicated selected.”^ If the defect is over muscle or 
by recurrent or persistent osteomyelitis, soft tissue, simple excision and closure or 
bony fusion in malposition, shortening of excision and skin graft will suffice. When 

244 American Journal oj Surgery 



Martin, Brauer — Soft Tissue Cover of Defects 


245 


j 



2B 2C 

Fig. 2. A, B and c, a double pedicle shift was used to 
cover two defects on the front of the leg in a case of 
bony fusion of the knee. 

the defect is over bone or tendon, pedicle 
tissue usually is required.^ 

This paper deals with the various types 
of pedicle tissue and the indications for 
each. The source and the method to be 
employed in obtaining this tissue is deter- 
mined by the location of the defect, its size 
and the type of bone and tendon surgery 
contemplated. We attempt to simplify our 
procedure as much as possible. When it is 
feasible, we prefer to use tissue adjacent 
to the defect. Unfortunately, the defects 
we have encountered usually have been too 
extensive for this type of procedure. In 
these cases, in the further interest of 
simplicity and speed we have attempted to 
use some • variation of the open flap. Ab- 

February, ig^o 



Fig. 3. A, B and c, a local flap was used because of 
the good circulation about the knee and its 
simplicity. 

dominal tube pedicles are of great value in 
selected cases. We reserve their use to 
situations in which the other extremity is 
not available as a source of an open flap or 
in which such a flap would be unsuitable. 

Double Pedicle. This procedure should 
be limited to linear defects in the upper 
two-thirds of the leg or thigh where the 
split graft of the secondary defect does not 
encroach on the tibia, popliteal space or the 
Achilles tendon. When there is bony fusion 
of the knee, the skin graft may be carried 
across the popliteal space with no fear of 
contracture. The double pedicle cannot be 
used to cover a cavity unless the latter is 
shallow. Occasionally the space can be 
filled with a small local flap of muscle or 
fat at the time the pedicle is shifted. This 
is an excellent procedure but limited in its 
application. We have found it desirable to 
delay the pedicles at least once when their 
elevation involves undermining extensively 
around the knee joint. (Figs, i and 2.) 



246 


Martin, Brauer — Soft Tissue Cover of Defects 



4A. 4B 

Fig. 4. A and n, jeep accident August 12, 1944, resulting in non-union of the tibia. This case illustrates the fact that 
the (lap should be broad, extending into normal tissue around it. This is especially true in cases showing pigmenta- 
tion and induration about the defect. 



5A 5 B 5c 

Fig. 5 . A, B and c, a cross-leg flap from opposite calf was used in preparation for a bone graft. Note the skin graft 
used to line the flap and bed. 


Transposition or Local Flap. This pro- 
cedure has limited application and is 
fraught with some danger. Many of the 
same principles apply as in the case of the 
double pedicle. It is useful in the upper 
third of tbe leg where a double pedicle shift 
would be difficult and is especially valuable 
about the knee where there is good circula- 
tion. Whenever possible the bases of these 
flaps should be near the point of emergence 
of a blood vessel through the fascia as, for 
example, the collateral vessels at the knee 
joint. This procedure consequently has 
little application in the distal third of the 
leg. (Figs. 3 and 4.) 

Calf Flaps, Cross-Leg. This procedure 
is the method of choice in handling defects 


of the leg requiring pedicle cover from a 
distant area. These flaps may be used 
either direct or retrograde and on any 
surface of the leg except over the tibia. 
The ideal flap is one based ^directly on 
either the posterior or posteromedial sur- 
face since the greatest blood supply to the 
skin comes from the recurrent vessels about 
the medial aspect of the knee. (Figs. 5 
and 6.) 

Thigh Flaps. A fairly large percentage 
of lower extremity defects are located in 
the distal third of the leg. If the deformity 
is a “rat hole” in the bone, a tube pedicle 
is often required. If the defect is in the 
nature of adherent scar or atrophic skin 
graft overlying the tibia or the Achilles 

American Journal of Surgery 


247 


Martin, Brauer — Soft Tissue Cover of Defects 



7A ' . . 7® ■ 

Fig. 7. A and b, non-union of tibia; cross-thigh flap was used because of its availability and the great volume of 

tissue required. 


tendon, we employ the open thigh flap 
because of its simplicity and the time- 
saving factor.'* (Figs. 7 to 9.) 

We prefer this method to the calf flap. It 
is less involved mechanically, being more 
direct. These thigh flaps may be either 
direct or retrograde. Of course the former is 
preferred but the recurrent vessels about 
the knee are adequate to the demands of 
either. Flaps on the lateral aspect of the 
thigh require a longer time to develop an 
adequate blood supply than those on the 
anterior or medial surfaces. If the defect 
on the leg can be covered with a short, 
broad flap, this flap can be attached directly 
at the time of its formation. These primary 
flaps should be outlined so that the base is 

February, ig§o 


broad. Their length should rarely exceed 
the width of the base. 

The point in favor of the thigh flap is the 
large amount of tissue of reliable blood 
supply which can be secured. Its disadvan- 
tages lie chiefly in the fact that these flaps 
are thicker than calf flaps and the patient’s 
position is not as comfortable. We prefer 
not to use them on the foot because 
of their bulkiness and slow acquisition of 
sensation.® 

Thigh Tube. We wish to mention thigh 
tubes only as a matter of record. We have 
done a few but do not believe that they are 
as satisfactory as the open flaps; the time 
Involved is usually much greater. In cases 
in which thigh tubes might be indicated, we 


248 


Martin, Brauer — Soft Tissue Cover of Defects 



8a 8d 8c 

Fig. 8. a, b and c, a retrograde thigh flap was used to replace the adherent cicatrix in preparation for orthopedic 
work. 



9A 9B 

Fig. 9. A and b, gunshot wound; required pedicle cover for an onlay bone graft and triple arthrodesis. 


use the tubed abdominal pedicle carried 
at the wrist. 

Open Abdominal Flap. The open ab- 
dominal flap or “jump flap” is first 
attached to the forearm.® After appropriate 
delays it is migrated to the defect. (Figs. 10 
to 12.) 

Its use should be limited to carefully 
picked cases. It is most useful in those 
cases in which it is necessary to move a 
large mass of tissue. The defect must be 
located so that the move is mechanically 
feasible.’ A mass of pedicle tissue 8 by 9 
inches has been moved in fourteen weeks. 
The disadvantages of this method are the 
short pedicle, which makes positioning 
tedious, and the difficulty in achieving a 


completely closed system, which we believe 
is vitally necessary when bone is likely to 
be exposed. 

Abdominal Tube to Extremities. This 
procedure is reserved for all defects which 
are so located and of such a nature that 
none of the aforementioned methods are 
suitable. 

Many of the bony cavities which have 
been lined by a split graft must be covered 
by a tube pedicle.® In these instances the 
tube is allowed to bridge the defect until 
it has gained adequate circulation. It is 
opened, the lining of the bony cavity 
removed and the defect filled with can- 
cellous bone chips. The opened tube is 
then used to cover the bone chips. The 

American Journal oj Surgery 



:Martin, Brauer— Soft Tissue Cover of Defects 


249 


lOA 


IOC 



Fig. 10. A, B, c and d, patient had a defect 8 by 9 inches. The location and size of the defect dictated 
the use of an open abdominal flap. Mechanically these must be perfect. 


tube pedicle is particularly useful in long 
defects on the surface of the leg. The fat 
carried in the tube is a great aid in filling 
in gutter-like defects in the bone. This 
method is also of value in cases of multiple 
defects on a single extremity. Its disadvant- 
ages lie chiefly in the time required for com- 
pletion and the slow return of sensation. 

We believe that the attachment to the 
wrist is the vital step in this procedure. All 
parts should be encased in a plaster cast 


since any compromise of the wrist attach- 
ment places the tube in jeopardy through- 
out its course. 

COMMENT 

We have made no mention of the prepa- 
ration of the recipient site. The general 
principles of bed rest, elevation, pressure 
dressings, excision of ulcers and skin graft 
to secure healing are well known. Occa- 
sionally it is necessary to cover open areas 


February, ig^o 



250 


Martin, Brauer — Soft Tissue Cover of Defects 



lie IID 


Fig. 1 1, a, b, c and d, traumatic amputation of the right leg; an abdominal tube pedicle was used, 
because of the opposite leg amputation and the nature of the defect, to replace the unstable 
cicatrix. 


with pedicle tissue. These areas must be 
surgically clean and even then the proce- 
dure is not without a calculated risk. 

We have had some experience with pre- 
casting for teg and thigh flaps. This is a 
procedure of merit but is time consuming, 
allows little latitude for last minute changes 
and there is some danger of compromising 
the sterile fields. In the hands of a meticu- 
lous and patient surgeon this procedure 
contributes materially to the comfort of 
the patient and the morale of the operating 
room personnel. 


The technic of these procedures is not 
stereotj'ped but there are a few guiding 
principles. These are simply the main- 
tenance of blood supply and freedom from 
infection. We have avoided the subject of 
the methods of delays since we believe 
that there must be considerable latitude. 
Each flap or tube must be considered indi- 
vidually and its physical condition used as 
a guide to the next step. 

SUMMARY 

The problem of coverage of soft tissue 
defects of the lower extremity is presented. 


American Journal of Surgery 



Martin, Brauer— Soft Tissue Cover of Defects 


251 



I2C 

Fig. 12. a, b and c, patient required pedicle cover in preparation for a bone graft. 


In view of its simplicity and speed, the 
writers prefer some variation of the open 
flap wherever possible. 

REFERENCES 

1. Beekman, Fenwick. The use of pedicle graft for 

chronic osteomyelitis. S. Clin, North America, 
17: 185-190, 1937. 

2. McDonald, Joseph J. and Webster, Jerome P. 

Early covering of extensive traumatic deformities 
of the hand and foot. Plast. & Reconstruct. Surg., 

1 : 49-57. 1946. 

3. Ghormley, Ralph K. Repair of deep skin defects of 

February, ig^o 


foot and ankle. Am. Acad. Ortbop. Surgeons, Led., 
pp. 107- 1 1 2, 1944- 

4. Lewis, George K. Skin defects of the e.xtremities. 

Am. Acad. Ortbop. Surgeons Led., pp. 229-245, 
1944. ■ 

5. McCarroll, H. R. Regeneration of sensation in 

transplanted skin. Ann. Surg., 108: 309-320, 1938. 

6. Cannon, Bradford et al. The use of open jump 

flaps in lower extremity repairs. Plast. & Recon- 
struct. Surg., 2: 336-341, 1947. 

7. McDonald, Joseph J. and Webster, Jerome P. 

Op. cit. 

8. Macomber. Walter B. and Rubin, Leonard R. 

Tubed pedicle complications in repair of massive 
tissue defects. Plast. & Reconstruct. Surg., 2: 10—20, 
1947. 



ABDOMINAL TRAUMA 


A CLINICAL STUDY OF 200 CONSECUTIVE CASES FROM THE MASSACHUSETTS 

GENERAL HOSPITAL 

Claude E. Welch, m.d. and W. Philip Giddings, m.d. 

Boston, Massachusetts 


T he interest in abdominal trauma 
occasioned by the recent war has led 
us to review the experience of the 
Massachusetts General Hospital with in- 
juries of this type that have occurred since 
1930. It is pertinent to ascertain wherein 
civilian and military experiences resemble 
or differ from one another and to determine 
what lessons of military surgery may profit- 
ably be applied in civilian practice. 

For this purpose the records of 200 con- 
secutive cases of abdominal trauma have 
been reviewed. These represent all such 
injuries treated in the public or private 
wards of the hospital between January i, 
1930, and April 30, 1948. 

It must be recognized that this hospital 
does not receive the majority of persons 
suffering from trauma in this city since 
most of these patients are taken to mu- 
nicipal institutions. However, the series of 
cases provides a typical cross-section of the 
patients observed in this community during 
this period. 

This comparative study emphasizes sev- 
eral important features: (i) The group of 
patients differs in several important respects 
from that observed in military practice; 
(2) the operative mortality has declined 
significantly in recent years; and (3) the 
methods of treatment are applicable equally 
to both groups of cases. 

COMPARISON OF WAR AND CIVILIAN 
EXPERIENCE